Sunday, January 10, 2010

Only chapter on the topic in any psych. nursing text, 7th edn.

By stroke of good luck, I met Lee Schecke (SHWEHkey) at a SMART conference. She retired from the Indianapolis nursing faculty of Indiana University a semester before my own retirement. Semester after semester, she agreed to come to my classes to introduce especially the topic of multiple personalities, now psychiatrically labeled dissociative identity disorder. She continues her own work at an Indianapolis hospital that has become known as a place where trauma is noticed and respected. Lee has just sent me the copy of the latest edition of her chapter. She has become a leading authority to me and countless students on realities of trauma and the defenses it produces...and suggestions for treatment. Feel free to e-mail lschweck@iupui.edu anytime. She is a wonderful speaker. In the past Lee gave me permission to share revisions of her chapter with students. I'm presuming she won't sue me if I distribute this latest writing of hers. Happy new year Lee! Love and peace--hal

Chapter 41Survivors of Violence and TraumaLee H. SchweckeLearning ObjectivesAfter reading this chapter, you should be able to:• Recognize the seriousness of violence and trauma in the United States.• Describe the emotional reactions of adult victims of crime, workplace violence, terrorism, torture, ritualabuse, mind control, human trafficking, rape and sexual assault, childhood sexual abuse, and partner andelder abuse.• Recognize the dynamics involved in interpersonal violence crimes.• Analyze the way in which the cycle of violence inhibits individuals from leaving abusive relationships.• Identify the needs of victims of violence and trauma.• Describe strategies for facilitating the transition from victim to survivor of violence or trauma.• Develop a nursing care plan for survivors of violence and trauma.he victimization of any individual by another creates serious mental health, social, community, andlegal problems. Violence in all forms is prevalent in this society. Nurses, regardless of their areas ofpractice, will come into contact with the victims—as inpatients, outpatients, home care patients,emergency care patients, parents of patients, friends, and relatives. Although the victims are typicallyseen initially for physical injuries, their psychological needs require attention if long-term mental healthproblems are to be prevented.Forensic nursing,(including sexual assault nurse examiners-SANE) is emerging as a vital aspect of theholistic care of victims and perpetrators of violent crimes and their families (Peternelj-Taylor, 2001). This careincludes obtaining clinical histories, documenting evidence, including photographs of injuries, and carryingout quality nursing interventions in a holistic care framework, which includes consideration of all the medicallegalaspects of the patient’s problems (Hammer, 2000). The rights of the alleged perpetrators of crime,suspects, and victims must be protected so that the legal cases will not be jeopardized (Piercy and Greenwood,2002).This chapter focuses on victims of violence and trauma, beginning with a brief overview of generalreactions to any crime, workplace violence, terrorism, torture, ritual abuse and human trafficking, followed bya more in-depth look at rape survivors, adult survivors of childhood sexual abuse, individuals abused by theirpartners and abused elderly. A small number of perpetrators of rape, sexual abuse, and partner abuse arefemale, but the more common pattern of this victimization is males against females. The short- and long-termreactions of victims described in this chapter are generally true for both male and female victims; however,men sometimes have a more difficult time admitting to and dealing with their emotional victimization thanwomen. The added impact on males of sexual violation by other males, both as children and as adults, is aresult, in part, of their fears about homosexuality (Maso and Anderson, 2008; Shea, 2008).Norm’s NotesIf ever there was a timely topic, this is it. I read just this morning in my local paper about ahusband and wife who were arrested on child pornography charges. The national evening news yesterdaycentered on a report about a sophisticated ring of child pornographers who committed deeds so barbaricthat the newscaster refused to describe them on the air. The victims, when they survive such abuse, arepotentially scarred for life. How in the world do they ever learn to trust again? Lee Schwecke has had alot of experience with survivors of violence and trauma, and has a lot to share in this chapter.Beyond the scope of this chapter are the issues of natural disasters (see Chapter 31), peer victimization andcrime and violence by children and adolescents, despite national attention to gangs, school shootings,Tbullying, hate crimes against certain populations, robbery, property damage, fighting (with or withoutweapons), cyber sex, cyber bullying, and drug related crimes.VIOLATION BY CRIMEEFFECTS OF CRIMESAt least 1.6 million individuals were seen in Emergency Departments for physical injuries caused by assaultsin 2005 (Simon, Kresnow, Bossarte, 2008). Not all crimes involve physical violence, injury, and threat to life;however, all crimes involve emotional violation and trauma. The victim’s identity is affected, even with theloss or destruction of possessions and property, because these are a representation of an individual’s identityand have personal significance. Crime undermines foundations formed in the first two stages of humandevelopment, regardless of the victim’s age when the crime occurred (see Chapter 4). There is a loss of trust,not only in the criminal, but also to some degree in all other individuals. Victims also lose self-esteem, a senseof ability to control their own lives and themselves (autonomy issues), as well as having identity issues(Rowell, 2005).Emotional reactions to crime vary greatly according to the individual, his/her resources and past history,the situation, and the meaning of the crime to that person. However, common reactions are denial, fear,anxiety, anger, powerlessness, and depression. A sense of failure and guilt is common; victims wonder whatthey did to cause the crime and how they might have prevented or stopped it. Victims usually feel ashamed andunworthy, as well as contaminated or dirty, whether or not they were physically touched by the perpetrator.Fantasies of revenge or a wish for legal retribution are typical. The relationships of victims to family andfriends can be disturbed, in part, because of the loss of trust, but also because of the response of others. Caringindividuals often imply that the victim was responsible for the crime, with questions such as, “Why were youthere alone at night? Why were you carrying so much cash? Why didn’t you install that burglar alarm?” Thevictim might feel alienated and isolated. Hospital personnel, the police, and the legal system might alsounwittingly convey what could be called a "blame the victim" attitude in their manner of questioning and infocusing only on the facts, without any emotional support or empathy. Long term effects of crime may result inprolonged stress, PTSD, depression, substance abuse, suicidality, and unhealthy weight control (Amar andClements, 2009).Workplace violence is a particular crime that is getting increased employer and media attention recently andis included here because, in 2 surveys in nonpsychiatric and psychiatric settings, 13%-21% of nurses reportincidences of physical violence and 34%-55% report emotional/verbal violence in the past year (Lanza, Zeiss,Rierdan, 2008). Workplace violence includes verbal abuse, sexual harassment, stalking, assault and battery,rape, and murder perpetrated by patients or their visitors, other employees, former or current partners ofemployees, and intruders from the outside looking for specific items, such as money or drugs (Gilmore-Hall,2001; Institute for Safe Medication Practices, 2004). One study by the National Institute of OccupationalSafety and Health in 2006 found that "nearly 5% of the 7.1 million private industry business establishmentshad an incident of workplace violence within the 12 months (Amar and Clements, 2009). According to thestudy by Nursing Management, 80% of nurse leaders have experienced some form of workplace violence atwork. Of these nurse leaders, 73% reported that "workplace violence is experienced occasionally";"frequently" was reported by 19%; and 1.7% said "always" (Hader, 2008).Verbal abuse by other employees includes intimidation, condescending language or tone, reluctance orrefusal to answer questions, withholding Information, negative or threatening language, angry outbursts, rudegestures, property damage, threats to or actual reporting of the nurse to a manager, ostracism, offensive notesor e-mail, criticism, humiliation, screaming, sabotage, and threats with weapons (APNA, 2008; Center forAmerican Nurses, 2008; Institute for Safe Medication Practices, 2004; Hader, 2008; Leiper, 2005). Verbalabuse, especially when the abusers are physicians, nurse managers, or supervisors, has been linked to the highturnover of nursing staff (APNA, 2008; Center for American Nurses, 2008; Gates, 2004; Hader, 2008; Leiper,2005)and, indirectly, to the nursing shortage.Sexual harassment is defined as "an unwelcomed sexual advance or conduct on the job that creates anintimidating, hostile, or offensive working environment...[ranging from]...repeated offensive or belittling jokesto pornography or outright sexual assault" (Farella, 2001, p. 14). According to a 1988 survey of the federalworkforce, 42% of all women and 15% of all men have experienced some form of harassment (Farella, 2001).Stalking is a crime that can occur anywhere but often occurs in the workplace. Stalking is obsessionalpursuit, harassment, and intimidation by a person who has or believes that he or she has a significant personalrelationship with the object of his or her unwanted attention. Stalkers might send letters, packages, or e-mails;make harassing phone calls; or follow and/or appear repeatedly at the victim’s home or workplace. Sometimesthey kill pets, vandalize or destroy property, and physically or sexually assault, or even murder their victims(Hughes, Thom, Dixon, 2007; Muscari, 2005). Surveys indicate that 2%-7% of all men and 8%-16% of allwomen have been stalked at least once in their lifetimes (Amar and Clements, 2007; Hughes, Thom, Dixon,2007). Men account for 87% of the stalkers, and women are their victims in 60% of cases. However, somecases involve female-male, male-male, or female-female stalking (Muscari, 2005).The media tends to focus on the stalking of celebrities and public officials by strangers. The stalkers in thesecases tend to be psychotic or have delusions about their victims and the supposed love relationship. However,most cases of stalking occur as the victim is trying to end a casual, dating, or marital relationship. This patternis more likely than celebrity stalking to involve physical violence (80%) and sexual assault (30%) and to becarried out by nondelusional individuals (Mawson, 2005).The Occupational Safety and Health Administration (OSHA) encourages voluntary compliance byemployers with their workplace violence guidelines, published in 1998. Briefly, these and other guidelinessuggest the following: (1) systematic education of all employees about verbal abuse, sexual harassment, andother forms of violence, along with ways to prevent and deal with them, Including conflict resolution andnegotiation skill training; (2) development of corporate policies and procedures related to workplace violenceand reporting procedures; (3) definition of roles for supervisors, employee health staff, and security personnel;and (4) provision for treatment and counseling for employee victims (APNA, 2008; Miller, 2008; Morrisonand Love, 2005; Trossman, 2001). Counseling is most often provided by Employee Assistance Programs(EAPs) (Paul and Blum, 2005).RECOVERY FROM VIOLENCE AND TRAUMAMany models have been formulated about the process of recovery from traumas such as crimes and disasters.Most researchers agree that the duration and severity of the trauma, the victim’s resources, and the nature ofhelp available during and immediately after the crime, trauma, or disaster influence recovery. Typically, threestages of recovery are defined: (1) initial disorganization (impact), (2) a struggle to adapt (recoil), and (3)reconstruction (reorganization). The brief summary here is derived from the views of Foa (2005), Lacy andBenedek (2003), Pasquali (2003), and Tynhurst (1951). The stages are not clearly separated, and thereadjustment process is not smooth. Vacillation among the stages might occur, and recovery might takemonths or years, especially if revictimization/secondary victimization (due to involvement with the criminaljustice system) continues after the crime (Baliko and Tuck, 2008).ImpactThe initial reaction to a single-event trauma usually lasts from a few minutes to a few days. Commonresponses are shock, denial, disbelief, and confusion. There might be paralyzing fear, hysteria, horror, anger,rage, shame, guilt, a sense of helplessness and vulnerability, physiologic responses, and disturbed sleeping andeating. These reactions might occur for a longer time when the trauma is ongoing, such as harassment,stalking, or disaster. Some victims react less visibly or in a delayed manner; they look calm, organized, andrational, and take all the necessary actions initially needed. Later, the other reactions might occur.Occasionally, the victim’s reaction might include dissociative symptoms (amnesia, depersonalization,numbing, detachment), intrusive memories (nightmares, flashbacks), and severe anxiety. These symptomsmight indicate that the victim is experiencing acute stress disorder (ASD) (see Chapter 31).RecoilIn the recoil stage, victims begin the struggle to adapt. The immediate danger might be over, but a great deal ofemotional stress remains. In the beginning of this phase, there are periods in which victims look and act normaland are able to carry out daily routines at home and at work. Activity helps suppress fears, anger, and sadness.Later in this phase, there is a desire to talk about all the details of and feelings about the trauma (“Whathappened?”). Victims often have a need for support and to be temporarily dependent. Fantasies of revenge forthe crime are natural during this stage. In the weeks and months following trauma, victims gradually becomeaware of the full impact that the event has had on their lives.ReorganizationReorganization might take months or years to accomplish. Although the trauma is not forgotten, the anxiety,fear, and anger diminish, and victims reconstruct their lives. The beginning of this phase includes reviewingand organizing what happened and why (“Why me?”); attributing blame to self, others, or both; justifyingone’s own actions at the time and later (“Why did I act the way I did then and since then?”); and regaining asense of control and self-protection. Grief over losses resolves slowly. Lingering nightmares, frustrations, anddisillusionment might occur; however, these subside as victims become reengaged in life and activities. Ifreorganization is not effective, victims might experience degrees of symptoms that, in some cases, areclinically diagnosable (e.g., posttraumatic stress disorder [PTSD]) and need appropriate treatment (Alim, et al,2008; Lacy and Benedek, 2003; Naifeh, et al, 2008; Roberts, et al, 2009). See Chapter 31.Even with satisfactory recovery, victims sense that they and their lives are, and always will be, different as aresult of the crime (“What if it happens again?”). Moving from victim to survivor or victor status is the goal forthose experiencing trauma (Rowell, 2005), which can be accomplished by integrating the memories of thetrauma and moving on in life with restored functioning, a reasonable sense of safety and security, healthyrelationships, improved self-esteem, and a sense of purpose in life (Alim, et al, 2008).PUTTING IT ALL TOGETHERPsychotherapeutic ManagementNURSE-PATIENT RELATIONSHIPAlthough trust, empathy, emotional support, and a willingness to listen are important in all stages of recovery,specialized care is needed in each stage. During the impact stage, the focus is on the survivor’s need forphysical safety and emotional security (see Chapter 10 for these crisis intervention strategies). Reassurance,protection from further harm, and sometimes medical care are needed. Survivors might need clear, simpledirections on what to do, where to go, and what to avoid. It is crucial that nurses avoid accusations (blaming),intimidations, unnecessary intrusions, and invasion of privacy. In most instances, crisis intervention occursface to face at the scene of the trauma or in the emergency room. For survivors who are superficially calm andin control, the crisis intervention might be needed a few hours or days later, when the trauma reality hits.Phone numbers for crisis telephone or walk-in services can be given to survivors before they leave the policeinterview at the scene or the emergency room.During the recoil stage, survivors need validation of their worth and rights as victims. Referrals can bemade to a victim’s assistance program and for legal, insurance, or financial assistance, if needed. If family andfriends are not fully available during the episodes of emotional turmoil in the recoil phase, then short-termcounseling might be beneficial. During the struggle to adjust, support groups with other survivors can beuseful. Whether the group is of short duration (6 to 8 weeks) or ongoing, and whether the group isprofessionally led or self-led, there is value in receiving information, encouragement, and companionship fromothers “who have been there.”During the reorganization stage, most survivors are able to recover and grow with minimal assistance.Appropriate humor might play a role in decreasing aggression and stress (Dietz, 2007; Pasquali, 2003). Longtermcounseling is sometimes needed to overcome anxiety, phobias, depression, suicidal ideation, or otherposttraumatic symptoms. It is uncommon for survivors to need hospitalization beyond initial medical care.Exceptions include survivors who are unable to function or meet their basic needs, or those who becomesuicidal.PSYCHOPHARMACOLOGYSurvivors of crime do not generally need medications. Antianxiety agents (benzodiazepines) are prescribedoccasionally for short-term use to decrease anxiety and facilitate sleep.MILIEU MANAGEMENTMany communities have temporary or ongoing groups for survivors of disasters, divorce, death of a loved one,sudden infant death syndrome (SIDS), rape, incest, and physical and emotional abuse, as well as for thoseaffected by suicide/homicide, mass murders, torture, and abduction of children.TERRORISMNATURE OF THE PROBLEMSeptember 11, 2001 is the day that awakened the United States to the realities of terrorism and itsunpredictability and devastation. Before this day, terrorism was a news story about terrible acts in foreigncountries. Terrorism can be perpetrated under the justification of various military, political, social, cultural, orreligious reasons. Acts of terrorism can involve plane crashes, bombings, military warfare, biologic andchemical agents, trained or programmed assassins, and suicide/homicide bombers. Terrorism rarely affectsonly a single individual; victimization can involve thousands who have been injured or killed in a single event.The victims of terrorism include those who were injured or killed; police, fire, and rescue personnel;businesses and their employees; the friends and families of all the victims; and potentially anyone whowitnessed the tragedy (directly or through the media).EFFECTSTerrorism can have more devastating results than natural disasters or major accidents because terrorism is notonly perpetrated by humans, but it is also not accidental. The purpose of terrorism is to terrorize, kill, or injuretargeted groups and to generate fear that it will happen again (Foa, 2005; Pasquali, 2003). The trauma ofterrorism is more pervasive, long-lasting, and severe than other violent crimes. Survivors typically experiencesome degree of grief and mourning and acute or posttraumatic stress symptoms, which are expected reactionsto an abnormal and horrifying event. See Box 41-1 (p. 608) for a list of typical reactions to terrorism. Theevent might also retrigger memories of previous traumatic experiences or lead to new or exacerbation of preexistingdisorders (Ai et al, 2005).RECOVERYMost individuals will recover with the support of loved ones, co-workers, and friends; memorial or religiousservices and community meetings; sleep, stress management techniques, relaxation techniques, physicalactivities; and a return to normal activities (Dietz, 2007; Foa, 2005; Miller, 2005). Critical incident stressmanagement strategies (described with PTSD in Chapter 31) can also facilitate recovery and prevent otheruntoward consequences (Dietz, 2007; Lacy and Benedek, 2003; New York Academy of Medicine, 2005;Pasquali, 2003).A major goal of recovery is to regain some sense of trust, safety, and security while acknowledging thatfuture terrorist attacks are possible. In general, recovery will parallel the stages of recovery described earlier(impact, recoil, and reorganization) but might be lengthier and more complicated, depending on the severityand duration of the trauma. On a larger scale, most cities and hospitals are reviewing their disaster plans for thecapability to respond to terrorist attacks, biologic and chemical warfare, large-scale bombings, and otherdisasters. For many cities, an effort has been made to improve city-wide, coordinated plans among police, fire,and rescue agencies, as well as hospitals, mental health facilities, and local, state, and federal emergencymanagement administrations. Psychiatric nurses and mental health personnel with mental health disastermanagement skills are included in the planning.Box 41-1Specific Responses Resulting From Terrorism, Torture, Serial Ritual Abuse, Mind Control, Human TraffickingShock, disbelief, fear, anxiety, powerlessnessInsecurity, guilt, shame, spiritual distressUnresponsiveness, dissociation, numbnessDecreased concentration, confusionPanic, terror, sense of violation, anger, rageAggression, fantasies of revenge, impulsivenessHelplessness, hopelessness, despairSuicidal or homicidal ideation, self-mutilationMistrust, suspiciousness, paranoia, alienationEstrangement, withdrawal, isolationFatigue, insomnia, nightmares, flashbacksMemory disturbances, amnesiaHyperarousal, stress sensitivity, startle responseDenial, repression, suppression, intellectualizationBody kinesthetic memories, psychosomatic symptomsExtreme passivity, loss of self-esteemDepression, prolonged grieving, substance abuse, PTSDSexual dysfunctions, eating disorder, anxiety disorderLabile emotions, personality changesModified from van der Kolk B, McFarlane AC, Weissaeth L: Traumatic stress: the effects of overwhelming experience on mind, body, andsociety, New York, 1996, Guilford Press; Turkus JA: The treatment challenge, Many Voices 12:6, 2000; Anorexia Nervosa and AssociatedDisorders (Indianapolis Chapter of ANAD): Personal interviews: Indianapolis, 2002, ANAD; Valente S: Controversies and challenges of ritualabuse, J Psychosoc Nurs 38:8, 2000; Miller MC: Disaster and trauma, Harv Ment Health Lett 18:1, 2002; Lacy TJ, Benedek DM: Terrorism andweapons of mass destruction: managing the behavioral reaction in primary care, South Med J 96:394, 2003; Cole H: Human trafficking:Implications for the role of the advanced practice forensic nurse, J Am Psych Nurses Assoc 14:6, 2009; Wessels S: Issues up close: The costlybusiness of human trafficking, Amer Nurse Today 3:12, 2009; Trossman M: Supporting the mental health and psychosocial wellbeing of formerchild soldiers, J Am Acad Child Adol Psychiatry 48:6, 2009; Sarson L, MacDonald L: Behavioural Harms: enforced and survival tactics in ritualabuse-torture victimization, Paper Presentation at the 31st SALIS Conference, May 8, 2009.TORTURE, RITUAL ABUSE, MIND CONTROL, HUMAN TRAFFICKINGNATURE OF THE PROBLEMPublic and professional attention to the effects of torture, serial ritual abuse (SRA), mind control (MC), humantrafficking (HT) on mental health has waned in recent years, although the crimes have not, according to thevictims. These crimes might be perpetrated by individuals, relatives, gangs, cults (satanic or nonsatanic), hategroups, organized crime, work/sex trade traffickers, or military-political organizations (e.g., Al Qaeda, theTaliban regime, Abu Ghraib Prison). Gangs are responsible for an increased number of homicides, otherphysical violence, and intimidation, according to the FBI (Ragavan and Guttman, 2004). The actions ofmembers of drug cartels in Mexico are another example of the destruction that can occur in a country. Theeffect is more severe because they involve multiple, calculated, and organized crimes against each victim orgroup of victims. This type of crime is used to create fear, humiliation, and submission in individuals,communities, and societies and is usually done for power and/or profit.Statistics on the prevalence of torture, SRA, and MC are not readily available because of the problems inacknowledging, reporting, and proving occurrences. The threat of further harm to the self, family, or pets tendsto keep victims silent. Especially in SRA and MC, perpetrators might use triggers to maintain victims’ silence orto control their actions, such as special words, hand signals, or greeting cards (Anorexia Nervosa and AssociatedDisorders [Indianapolis], 2002).Drug and MC experiments began before the 1970s (e.g., LSD experiments and covert military-politicaloperation [MK-ULTRA] programming that trained or programmed assassins for U.S. security forces) (Katchen,2005; McGonigle, 1999). MK-ULTRA operations (noted in movies—Conspiracy Theory, The Bourne Identityseries) are becoming more widely known, because the Freedom of Information Act has resulted in thedeclassification of military and political documents."Human trafficking (HT) is the equivalent of modern-day slavery" (Cole, 2009). It involves the transportationand harboring of individuals for the very profitable purpose of slavery, sex, forced labor and/or organ harvesting(Cole, 2009). Women and children, especially those in poverty, are particularly vulnerable. The kidnapping andholding of Elizabeth Smart may not have been for profit. Estimates for international trafficking are from 4-27million (Cole, 2009).TacticsAccording to survivors, torture involves physical, psychological, pharmacologic, MC, or sexual manipulation,or any combination of these aimed at damaging the victim’s identity, personality, emotional stability, spirit, andphysical integrity. HT tactics may include recruitment based on offers of money (to the victims and/or theirfamilies who sell the individual), a "better life", deceptions, threats, coercion, force, or kidnapping (Cole, 2009).Torture, SRA, and MC can begin with abduction and detention and end with execution, or can be ongoing overtime. Tactics also can include using hot irons, electric shock, submersion, suffocation, large doses ofdrugs/alcohol, beatings, physical restraint, confinement in cramped or buried containers, watching or forcedparticipation in others’ torture/killings, gang rape, sexual and physical mutilation, being tied and/or hung in theair, being photographed during the abuse, starvation, and sensory and sleep deprivation. There might also beprolonged interrogation, brainwashing, indoctrination, personality destruction/creation of multiple personalities,programming, threats to or lies about the safety of loved ones and pets, over-stimulation, mock executions,cannibalism, electronic harassment (microchip implants, as in the movie Manchurian Candidate), and threatswith weapons (ANAD, 2002; Dowbecko, 2005; McCollough-Zander and Larson, 2004; Sarson and MacDonald,2004 and 2009; Tolces, 2005; Valente, 2000).EFFECTSCommon outcomes of torture, SRA, MC, and HT are injuries to the head, teeth, and genitals, as well as bonefractures, dislocations, scars, burns, pain, chronic headaches, and forced pregnancies/abortions (Sarson andMacdonald, 2009; Wessels, 2009). There may be disruptions in the functioning of the prefrontal cortex due tothe prolonged stress (Liston, 2009). The emotional and other effects are more severe and longer lasting thanthose caused by other crimes. They include a sense of violation, dehumanization, humiliation, horrification,compulsive spending, guilt about harming others or animals, identity and personality changes, and damagedsocial and family relationships. In addition victims may reveal a fear of leaving home/work, of authority,revealing personal information, infections, STD's malnutrition, poor hygiene, and reproductive problems(Cole, 2009; Sarson and Macdonald, 2009; Trossman, 2008; Wessels, 2009). Trauma-specific fears (e.g., smalldark spaces or nudity), hypersexuality, and obsessions with rituals, magic, or devils are common. Victimsmight have been forced or programmed to commit crimes against others. They might talk about topics that donot make sense to professionals, such as the Greek alphabet, sex trade, white slavery, drinking blood, satanicrituals and holidays, and the Satanic Bible (written by Anton LaVey) (ANAD, 2002; Valente, 2000). Otherspecific responses resulting from torture, SRA, MC, and HT are listed in Box 41-1.There is much controversy about assigning psychiatric diagnoses (e.g., PTSD, adjustment disorder, majordepression, dysthymia, anxiety disorder, dissociative identity disorder, or other dissociative disorders) tovictims who are having typical reactions to horrific crimes (Torem, 2000). The major concern is that diagnosisis another form of victimization, stigmatization, and discounting of the validity of reports of these crimes.Blaming the victim draws attention away from the individual, social, cultural, and political variables creatingand fostering torture, SRA, MC, and HT and from research on strategies for prevention. Some professionalseven view PTSD as insufficient for acknowledging the catastrophic effects experienced by victims and theirfamilies. The Salvation Army and the U.S. Department of Health and Human Services have developed guidesfor Identifying and assessing HT victims. Another resource is The Crime of Human Trafficking (Office onViolence against Women, date unknown).RECOVERYBecause torture, SRA, MC and HT tend to be ongoing, the impact stage of recovery persists but might wax andwane over the years. In the recoil stage, adaptation is difficult because of the severity of the emotional stressremaining after these crimes end. Although supportive, cognitive-behavioral, psychodynamic, andpharmacologic approaches (Lacy and Benedek, 2003; McCollough-Zander and Larson, 2004) are useful inhelping these survivors reorganize their lives, this stage is likely to be prolonged, with more relapses duringother life crises. Admission to a specialized program or psychiatric unit might be needed during intensetherapy periods, when the risk of self-mutilation, suicide, or increased substance abuse is present. The majorgoals for recovery (Alim, et al, 2008; Cole, 2009; Howe, 2003; Lacy and Benedek, 2003; McCollough-Zanderand Larson, 2004; Sarson and Macdonald, 2009; Wessels, 2009) include the following:1. Decreasing, and eventually eliminating, self-destructive behaviors (self-mutilation, suicide attempts,substance abuse, and manipulation)2. Developing emotion management skills and acknowledging the thoughts, feelings, and behaviors as“normal reactions to abnormal situations”3. Expressing and dealing appropriately and safely with the intense emotions, especially anxiety, guilt, anger,rage, and desire for revenge4. Becoming aware of suppressed or repressed thoughts and feelings, positive emotions, and body memoriesand reactions5. Allowing oneself to grieve for the variety of losses experienced6. Processing and integrating the memories of the experiences, often from the least to the most bizarreexperiences (as in the recovery from PTSD and the integration of multiple personalities)7. Developing or re-establishing healthy relationships with family, friends, and the community8. Developing boundaries, a sense of privacy, self-integrity, and empathy9. Using complementary or alternative medicine and spiritual practices that are helpful10. Developing occupational and community living skills that lead to economic and social independence11. Becoming aware of new perspectives in life and reasons to live, in spite of the past12. Regaining a sense of hope, personal power, and control over oneself and one’s lifePUTTING IT ALL TOGETHERPsychotherapeutic ManagementNURSE-PATIENT RELATIONSHIPConveying acceptance, caring, and support; ensuring confidentiality; and believing what is being described arecrucial if survivors are going to trust someone enough to discuss their experiences (Cole, 2009; McCollough-Zander and Larson, 2004; Sarson and Macdonald, 2009). Survivors must have time and space to process theissues at their own pace and within their own cultural framework. Survivors might need prompting, which alsoconveys understanding, such as, “It sounds as if you have been traumatized in some way” or “I wonder if youhave experienced activities using rituals.” Strategies used with patients experiencing PTSD are particularlyuseful for survivors of torture, SRA, MC, and HT (see Chapter 31). Depending on the origin of the torture,SRA, MC or HT (individuals, relatives, gangs, hate groups, cults, organized crime, traffickers, militarypoliticalorganizations), it might be crucial to understand the survivor’s family, religious, cultural, and politicalbackground. Referrals for treatment or correction of physical injuries and other outcomes might be appropriate,such as dentists, plastic surgeons, gynecologists, neurologists, or gastroenterologists (Turkus, 2000). Survivorsmay also need support and protection while they are involved with the criminal justice when their perpetratorsare being investigated and prosecuted. Foreign survivors may require the use of translators and faceimmigration charges and deportation (Cole, 2009; Trossman, 2008).PSYCHOPHARMACOLOGYUsing medication for treating survivors of torture, SRA, and MC is highly controversial, especially becausedrugs were often a part of the abuse as it occurred. Sometimes the medications used in treating PTSD, anxietydisorders, depression (especially selective serotonin reuptake inhibitors, SSRIs), sleep disturbances, andpsychosis are effective (Lacy and Benedek, 2003; McCollough-Zander and Larson, 2004).MILIEU MANAGEMENTSpecialized treatment centers, such as the Center for Victims of Torture in Minnesota (McCollough-Zander andLarson, 2004) and The Center: Post-Traumatic Disorders Program in Washington, DC, use a multidisciplinaryapproach in providing treatment and rehabilitation for survivors and their families. Some of the 30 centers andprograms use bicultural counselors to facilitate counselling with immigrants and former gang members. Selfhelpand therapy groups might be useful for survivors with similar experiences and needs, such as politicalrefugees; rape, childhood sexual abuse, and partner abuse survivors; and former cult and gang members.Nurses and survivors of HT can access information and resources from the national hotline (888-373-7888) ofthe U.S. Department of Health and Human Services or The Trafficking in Persons and Worker ExploitationTask Force (888-428-7581).For further information about torture, SRA, MC, and HT, the following auto biographers have written theirown personal stories:Family torture: David Pelzer, Richard Pelzer, deJoly La BrierFundamentalist/polygamous cults: Brent Jeffs, Carolyn Jessup, Flora Jessop, Elissa WallMilitary-political SRA and MC: Carol Rutz, Kathleen SullivanRAPE AND SEXUAL ASSAULTNATURE OF THE PROBLEMStatistics indicate that rape is an underreported crime in the United States; probably only 1/3 of rapes arereported (Amar and Clements, 2009; Jordan, 2004). Valid statistics are not available for sexual assault and rapebecause of this lack of reporting. It is estimated that one in four adult women have been raped in their lifetime(Campbell and Wasco, 2005). In one survey, 14.8% of the females and 2.1% of the males reported having beenraped in the past year (Courey, et al, 2008). The elderly are vulnerable at home and in extended care facilities,especially if they have medical conditions, a physical or mental disability, or dementia (any of which mightresult in their reports being discounted by caregivers, family, and officials) (Burgess et al, 2005). Rape of menby men is increasing [an estimated 1 in 10 rape victims is male (Amar and Clements, 2009)], but is rarelyreported. Of the reported sexual assaults and rapes, probably 90% involve a male perpetrator and a femalevictim (Brown, 2001). The increasing availability of adult and child pornography through electronic mediamay be playing a role in the increasing rate of rape, sexual assault, and child sexual exploitation (Alexy,Burgess, Priestly, 2009; Burgess, et al, 2008; Courey, et al, 2008)One major problem in reporting rape is that laws and attitudes vary in different states and communities. Ingeneral, rape is considered forcible penetration of the victim’s body by the perpetrator’s penis, fingers, orobject without consent (Martin et al, 2000). Any other form of forced sexual contact (from touch to mutilation)is considered sexual assault. Despite sexual contact, it is generally acknowledged that rape is not sexuallymotivated, but involves a desire for power and control, a wish to humiliate the victim, and the playing out of a(sexual) fantasy (Brown, 2001). Some police and prosecutors still do not pursue rape as a charge if the twoindividuals know each other (Jordan, 2004), despite the fact that, in 90% of reported rapes, the victim knowsthe offender at least casually (Brown, 2001). In a longitudinal study of adolescents, findings were that 46%experienced sexual aggression and 65% of those experienced a repeated incident of sexual aggression (Youngand Furman, 2008). Date or acquaintance rape might be complicated by the use of amnesiacs (date rape drugs),other drugs, and alcohol, which interfere with remembering the rape (Osterman et al, 2001). Some states lackmarital rape statutes, or prosecutors are reluctant to charge husbands with raping their wives. Unfortunately,many in our society ignore rape or convey the message that anyone who is raped asked for it (blaming thevictim).EFFECTSSimilar to all crime victims, the rape victim experiences a severe violation and all the possible emotions of theimpact stage. In addition to internal and external bodily injuries, there might be a threat to life with weapons,to return and rape again, or to kill the victim if the rape is reported, or the perpetrator might kill the victimduring or after the rape (Brown, 2001). Victims usually live but wish they had died. The traumatic memoriesof the rape usually include tastes, smells, sounds, and sights, as well tactile sensations and physical pain(Brown, 2001). These memories and the powerlessness, loss of control, fear, shame, guilt, humiliation, rage,and feelings of being contaminated or dirty might be overwhelming. A typical reaction of the victim is thewish to regain a sense of control and retreat to a safe place, take a thorough shower, and destroy any damagedbelongings. To do this, however, would destroy most of the evidence that is required if the victim decides toreport the rape and prosecute. Avoiding medical attention also places victims at risk for acquiredimmunodeficiency syndrome (AIDS), hepatitis B infection, sexually transmitted diseases (STDs), pregnancy,and improper healing of any physical injuries (Campbell and Wasco, 2005; Piercy and Greenwood, 2002).Beyond the injuries, there may be long term effects of headaches, gastrointestinal disturbances, chronic paindepression, anxiety, substance abuse, and/or PTSD (Courey, et al, 2008)RECOVERYDespite an outward appearance of calm composure and a denial at times of the need for help (as in silent ordelayed reactions), the rape survivor needs assistance, information, and support. It might not be until thesurvivor begins the up and down struggle of the recoil stage that the losses, anger, and needs are recognized. Inan emergency department, collecting evidence, taking away clothes, and other procedures might be a priorityfor staff but, for the survivor, it is perceived as further intrusion and violation (Courey. et al, 2008). To staff,survivors might seem resistant and uncooperative, whereas survivors are trying to protect themselves andregain a sense of control (Brown, 2001). Box 41-2 lists some of the needs and rights of rape survivors.Box 41-2Needs and Rights of Rape Survivors1. Crisis intervention: information, counseling, and referrals2. Help with basic needs: housing, transportation, child care, safety3. Medical information and care: information about pregnancy prevention, testing for sexually transmitted diseases, follow-up care, andcounseling4. Advocacy for whatever choices are made about reporting or prosecuting5. Protection of rights: to privacy, confidentiality, gentleness, sensitivity, and explanations of procedures and tests6. Protection of rights: to refuse collection of evidence, to determine who will and will not be present during examinations, to get copiesof all medical and legal reports, and to apply for reimbursement through victim’s compensation7. Fairness, information, and protection of legal rights during investigations, hearings, and trial, including not being asked about priorsexual experiences with anyone other than the suspect or defendant8. Reasonable protection against further harm: escorts to court, restraining order, additional patrols, even relocation, if necessaryMany communities have developed specialized services for rape survivors (e.g., Centers for Hope) withinclinics or emergency departments. Sexual assault nurse examiners (SANE) have skills in collecting forensicevidence while providing empathy, support, and information (Campbell and Wasco, 2005). Nurses also canencourage the beginning of the recovery process by avoiding a "blame the victim" attitude and by challengingany myths stated by the survivors, such as, “I should have fought him off” or “I shouldn’t have been drinking”(Brown, 2001; Girardin, 2001; Piercy and Greenwood, 2002; Willis, 2009).Specialized rape services have information packets prepared for rape survivors and staff in hospitals,counseling centers, and other crisis areas. Survivors can be encouraged to keep the information sheets, as wellas phone numbers of resources, for later use. The temporarily composed and calm victim who denies the needfor help should be especially encouraged to take materials home. A SANE might also call a sexual assaultadvocate, an advocate from a victim’s assistance program, or a rape crisis counselor to initiate contact with thesurvivor and make periodic follow-up contact days, weeks, and even months later, when emotional, physical,or legal issues and concerns might arise (Brown, 2001; Campbell and Wasco, 2005).In the recoil stage, most survivors begin to react to the significant effect that rape has had on their lives;they might alternately deny and admit to experiencing turmoil. Fear and mistrust are major issues and might bedirected toward individuals resembling the perpetrator or toward everyone around them, especially if othersconvey any hint of blaming the victim. Survivors might be afraid to leave the one place they designate as safe.They might be able to go out with family and friends, but they more often avoid strangers, places similar to therape scene, and intimacy, especially sexual relationships. If the rapes occurred in their residence, survivorsmight move or at least make safety-related changes to prevent recurrence, or they might ask for someone tostay with them at night for a while. Being alone and unprotected is usually frightening, especially whennightmares and traumatic memories occur. Survivors need help in reaffirming that they are worthwhileindividuals, with dignity and rights, who did not cause and did not deserve the rape. They need to know thattheir anger is natural, especially about the violation of person and privacy, the humiliation, and the sense ofpowerlessness. Survivors often question whether they might have fought off the attacker. Survival is mostimportant; if the victim survived the rape, then he or she did exactly what was necessary to stay alive.RAPE TRAUMA SYMPTOMSOne way to monitor and evaluate the rape survivor’s responses to the trauma and recovery process through therecoil and reorganization stages is to assess periodically for improvements in the rape trauma symptoms(DiVasto, 1985):• Sleep disturbances, nightmares• Loss of appetite, somatic symptoms• Fears, anxiety, phobias, suspicion• Decrease in activities and motivation• Disruptions in relationships with partner, family, friends• Self-blame, guilt, shame• Lowered self-esteem, feelings of worthlessnessIt is important to remember that survivors vacillate in the recoil stage between repression or suppression anddealing with the trauma. Even progress in the reorganization stage is not smooth; backslides occur at times,especially if new situations trigger memories of the rape. Survivors might avoid future routine gynecologic andrectal examinations to avoid re-experiencing the trauma (Osterman et al, 2001). The use of restraints during aninpatient stay might also reactivate the trauma symptoms (Chandler, 2008). The goals of recovery from rapeand sexual assault are the same as those for all survivors of crime. In addition, rape survivors might need todevelop or regain healthy sexual functioning and relationships (Osterman et al, 2001). Victims need to transfertraumatic memories to narrative or past memories by processing the sensory memories and decreasing theirstrength and influence, enabling them to move from victim to survivor status (Brown, 2001).PUTTING IT ALL TOGETHERPsychotherapeutic ManagementNURSE-PATIENT RELATIONSHIPThe rape or sexual assault survivor needs continual empathy, support, and an opportunity to process the eventsand manage the intense feelings, as well as to regain a sense of psychological and physical safety (Osterman etal, 2001). Although it is more time- and energy-consuming, the best approach in collecting evidence andproviding nursing care is to move slowly and supportively at the individual survivor’s pace and to giverationales for and descriptions of procedures and referrals. Nurses can be particularly helpful to rape survivors.Male and especially female survivors tend to feel safer with a woman and might refuse to talk to a man,especially alone. The presence of a SANE or sexual assault advocate during examinations and interrogationscan be reassuring. Survivors might or might not choose to have a friend or family member stay with them foradditional support or help them get home. A sense of shame or guilt might interfere with reaching out forsupport (Osterman et al, 2001).Crisis intervention is the most appropriate approach during the impact stage. Short-term counseling and arape support group can be beneficial during the recoil stage. Long-term counseling might be needed during thereorganization stage, especially if the survivor decides to prosecute the perpetrator. A lengthy legal process canseriously delay recovery because of having to relive the events and emotions. In many trial situations, thesurvivor is still treated as a criminal during cross-examinations. On the other hand, conviction andimprisonment of the perpetrator can help survivors feel vindicated, compensated, and safer in theirenvironments.If the symptoms of rape trauma do not gradually diminish and if reorganization of lifestyle does not seem tooccur, the survivor needs to be assessed for and helped with any new problems, such as posttraumatic stress,anxiety, excessive anger and guilt, depression, acting out, isolation, suicidal thoughts, self-destructivebehaviors, eating and sexual disorders, substance abuse, phobias, and/or negative or destructive relationshipswith others, as well as reactivation of childhood sexual abuse memories (Campbell and Wasco, 2004; Faravelliet al, 2004). With any of these behaviors, longer term counseling might be a necessity and hospitalization forsafety becomes essential.PSYCHOPHARMACOLOGYAlthough rarely prescribed to rape survivors, benzodiazepines to reduce anxiety and provide for sleep might beused on a temporary basis. Alternatively, an antidepressant taken at bedtime (especially trazodone [Desyrel]),might be ordered if symptoms of depression exist with a sleep disturbance. If nightmares or traumaticmemories are severe, a low dose of an atypical antipsychotic such as risperidone (Risperdal) or quetiapine(Seroquel) might be indicated.MILIEU MANAGEMENTReferral can be made to a rape support group or center, which encourages expressing anger safely, overcomingguilt and shame, building self-esteem and trust, and assisting in regaining control of the survivor’s life and asense of safety. Support groups are sometimes available for relatives, especially partners, of rape survivors tohelp them deal with the trauma, stereotyping and myths, and changes occurring in the survivors, themselves,and their relationship with the survivors. Also available are The Rape, Abuse and Incest National Network(RAINN) National Sexual Assault Hotline (800-656-Hope) and the National Sexual Assault On-line Hotline(http://rainn.org) (RAINN, 2008).CLINICAL EXAMPLEA 24-year-old woman called a rape crisis line complaining of anxiety at work, not sleeping, fear of being out at night,overwhelming anger, and feeling dirty and ashamed. For several weeks she thought that a co-worker was watching her. LastFriday, as she was leaving work late, the co-worker pushed her into her car and raped her. She did not report the rape and hidin her apartment all weekend. She forced herself to go to work on Monday. The man acted friendly toward her, as if nothinghad happened.ADULT SURVIVORS OF CHILDHOOD SEXUAL ABUSENATURE OF THE PROBLEMApproximately 1 million cases of child abuse (including sexual abuse) are reported each year. However, childabuse is grossly underreported (Rick and Douglas, 2007). It is likely that the internet is compounding theproblem. One study found that approximately 14% of the 10-17 age group who were online, received a sexualsolicitation (Burgess, et al, 2008). The CSA crimes of child pornography, childhood sexual abuse (by nonrelatives)and incest (by relatives) are especially destructive for two major reasons: the crimes are not one-timeoccurrences, and the perpetrators may be known and trusted. Unfortunately, these crimes are common. Studieshave indicated that 15% to 30% of all girls and 4% to 16% of all boys have experienced childhood sexualabuse (Cook, 2005; Valente, 2005). The incidence of sexual abuse of boys might actually be much higher. Oneestimate is that 25%-35% of all CSA victims are male (Maso and Anderson, 2009). It is sometimes harder formen to reveal the abuse because of the fear of being seen as unable to protect themselves, weak, or gay (Cook,2005; Maso and Anderson, 2009; Shea, 2008; Valente, 2005). However, the number of children who havebeen sexually abused and never reported it, even when they became adults, is not actually known.Sexual abuse and incest include voyeurism and exhibitionism, which can lead to intercourse and mutilation,but always involve a younger victim who is not capable of giving consent to the older, more powerfulindividual. For 75% of the adult female survivors in one study, the abuse began before the age of 7 years and62% had multiple perpetrators (Jonzon and Lindblad, 2005; Valente, 2005). Male perpetrators are commonlyfathers, uncles, stepfathers, older brothers, cousins, grandfathers, neighbors, scout leaders, camp counselors,coaches, and religious leaders. Less frequently, the perpetrators are females—mothers, older sisters, otherrelatives, day care workers, teachers, coaches, neighbors, and babysitters. Perpetrators tend to choose eithermale or female victims, so there can be male to male, male to female, female to male, and female to femaleabuse. However, 92% of the females were victimized by male perpetrators and 38% of the males werevictimized by female perpetrators (Lie and Barclay, 2005a). Victims are from every social, cultural, ethnic, andeconomic group (Cook, 2005).Although sexual abuse can be violent, it often is not. Coercion is possible because of the victim’sdependent, trusting, or loving relationship with the perpetrator. The victim is urged to maintain the secret withvarious threats, such as the following: the victim will be taken away from the family; the perpetrator will beput in a mental hospital or jail; the parents will divorce; the other parent will get sick; there will be no abuse ofsiblings if the victim is compliant; love will be withdrawn; no one would believe the victim anyway; or therewill be physical abuse if the victim does not comply. Even when no physical violence takes place, victimsusually fear that it will occur if they resist the perpetrator. Factors such as family conflicts or disorganization,witnessing violence, parental loss, parental mental illness, economic instability, secrecy and communicationdifficulties, substance abuse, and other forms of abuse (emotional, verbal, physical) and neglect seem tocorrelate with sexual abuse (Davis and Petretic-Jackson, 2000; Gladstone et al, 2004; Goodwin, 2005).Even if the young victims want to disclose the abuse, it is difficult for them because they lack the words andconcepts to describe the event. An emotional reaction of fear and confusion usually occurs, and some physicalpain, but not a moral, ethical, or legal concept of right or wrong. Most victims who, as children, tried to tell aparent or other adult were often met with disbelief, denial, or pressure to retract their accusations. It is difficultfor a parent to believe that the partner they love or a respected member of the community is capable of sexualabuse. Police, prosecutors, judges, mental health professionals, and the general public might discount a child’sreport as unreliable, a fantasy, distorted, or faked at the urging of a parent, especially if there is a custodydispute in progress (Davis and Petretic-Jackson, 2000). There are also potential benefits from the sexualrelationship; the child is made to feel special, with extra attention from and time with the perpetrator that otherchildren do not enjoy. A certain power comes from pleasing the adult and receiving a degree of (distorted)affection (Davis and Petretic-Jackson, 2000). At times, the child might even have the physical experience ofsensual pleasure (Valente, 2005). However, the emotional pleasure and concept of adult sexual love are absent.(It should be noted that all children make bids for attention and affection. Even if they are cute, coy, orflirtatious, these desires should not be viewed as seduction. Perpetrators of sexual abuse choose to misinterpretthe child’s behavior to meet their own needs and should still be held responsible for the crime.)EFFECTS OF CHILDHOOD SEXUAL ABUSEOn the ChildFor the victim, the prolonged stress of the abuse might lead to changes in his or her neurobiology, as in thestress response described in Chapter 10. "Stress hormones affect myelination, neural morphology,neurogenesis, and synaptogenesis" (Rick and Douglas, 2007). Specific areas of the brain likely to be affectedby childhood trauma include the amygdala, cerebellar vermis, cerebral cortex, corpus callosum, andhippocampus (Rick and Douglas, 2007). Other results are disturbed growth and development (beginning withtrust and autonomy issues), ambivalence about the experience (both the benefits and the pain), and denial ofwhat is happening to protect the whole family or the community. The young child is fulfilling the roles of childand lover to the perpetrator, and roles of child and protector to the rest of the family or community (protectingthem from the horrible secret). As a result, the child begins a long-term process of taking care of others to theexclusion of personal needs. Basically, the child wishes for love, not sex, but eventually feels guilty, exploited,betrayed, angry, dirty, helpless, and responsible. Denial, repression, suppression, rationalization, anddissociation are mechanisms used by young victims to cope with this no-win situation. Sleep and eatingdisturbances, enuresis, anxiety, depression, aggression, an active fantasy life, masturbation, sexualized play,sexual aggression, poor impulse control, cruelty to animals, spiritual distress, somatization, alienation, fear,shame, self-blame, self-destructive behaviors, running away, and truancy are common (Cook, 2005; Davis andPetretic-Jackson, 2000; Valente, 2005). The more severe the abuse, the more likely that repression will beginnear puberty. If the sexual abuse continues throughout adolescence, repression is less likely. Repressionnormally lasts until victims are in their 20s or 30s and are having trouble with intimate relationships and/orparenting.CLINICAL EXAMPLEChildren who were examined following ritual abuse in a day care center reported being locked in a cage, put in a coffin, heldunderwater, injected with needles, tied and hung from hooks, sexually assaulted, and threatened with guns and knives. Thechildren were told that if they told anyone about the abuse, their parents, siblings, or pets would be killed.On the AdolescentAs adolescents, sexual abuse victims show mostly overt methods of dysfunctional coping, such as impulsiveacting out, violence toward or abuse of others, cruelty to animals, self-destructive behaviors, sleeping andeating disorders, suicide attempts, running away, truancy, delinquency, substance abuse, spiritual distress,sexual acting out, prostitution, early pregnancy, and early marriage (Cook, 2005; Davis and Petretic-Jackson,2000; Valente, 2005). For victims who cope through self-mutilation, these behaviors tend to begin between theages of 12 and 14 years (Cerdorian, 2005).Adolescents might have fantasies of revenge and wish for the perpetrator’s death. The anger toward theperpetrator and other adults (for not protecting them) approaches rage but is not directly expressed. Victimsmight not even be aware of the reason for their rage, shame, guilt, confusion, sense of alienation, and isolationand might not realize that their acting-out behaviors are related to the abuse. Regression, depression,depersonalization, dissociation, manipulation, low self-esteem, impaired social skills, spiritual distress, thoughtand memory disturbances, self-neglect, aimlessness, and withdrawal are common. Sexual abuse survivors arealso more likely than the general population to be raped and battered by partners in adolescence and later inlife (Davis and Petretic-Jackson, 2000; Gladstone et al, 2004; Kreidler et al, 2000; Valente, 2005).On the AdultFor many victims of childhood sexual abuse, the process of surviving childhood and adolescence andbecoming an adult is similar to delayed PTSD responses: repression of memories (even nonsexual ones),followed by a breakthrough of unwanted, intrusive memories. The memories might begin as nightmares,kinesthetic sensations (such as flinching or vaginal pain when touched by a partner in the same way as theperpetrator), or flashbacks. The memories might return gradually, in pieces, or in a sudden, overwhelmingflood. Victims cannot be rushed to remember the abuse before they are ready to cope with it.On the surface, adult victims might look relatively uninjured because of denial, dissociation, amnesia,emotional deadening, or repression. They enter counseling for manifestations of the abuse rather than for theincest or sexual abuse itself. The list of typical reactions in Box 41-3 can be used as a checklist to identify theissues to be addressed in counseling. Victims who see this list typically express amazement (that so much hasresulted from the sexual abuse) and relief (that there is finally an explanation for all their “craziness”). Up tothis point, victims might tend to deny or minimize the relationship of the sexual abuse to any of their currentproblems. It then becomes evident to victims that the event has disturbed their entire growth and developmentprocess and their self-esteem, and has set them up for other abusive relationships. Only one third of victimsever receive counseling specifically focusing on the childhood sexual abuse (Gladstone et al, 2004). Untilcounseling finally focuses on the anger and underlying cause of their reactions, victims tend to seek treatmentrepeatedly, without relief.The inability to handle the memories of abuse and the painful emotions, especially anger, often inducesthoughts of suicide to escape the pain and depression, to die with the secret, to avoid conflict with the family orperpetrator, to stop feeling “crazy,” and to end the nightmares and flashbacks that are so frightening. Self-harmor mutilation, without even feeling the pain, is a common way of dealing with the emotional pain, loss, rage,and abandonment. Dissociation during the mutilation is common. Victims describe various patterns of theirmutilation (ANAD, 2002; Cerdorian, 2005; Starr, 2004; Williams and Bydalek, 2009):1. When feeling overwhelmed, they inflict harm as a cry for help when they believe that no one is listening orcares.2. When emotions build up, they go numb or dissociate and have to inflict pain to make sure that they can stillfeel.3. When they are feeling unreal (depersonalization), they draw blood to make sure that they are alive.4. They cause physical pain so that they do not have to focus on the emotional pain.5. They punish themselves when they are feeling self-loathing, guilt, shame, or fear.6. They use the mutilation as a way of avoiding suicide.7. They use the mutilation to relieve the anger or rage toward self and others.8. They might use the mutilation as an attempt to manipulate others.9. The mutilation might become chronic and addictive, especially if it produces a high (related to endogenousopiates/endorphines).Box 41-3Adult Manifestations of Childhood Sexual AbuseMemory DisturbancesAmnesia about the abuseMemory gaps about childhoodInability to think straightKeeping Unnecessary SecretsRelationship IssuesTrouble connecting with othersRunning away from othersFear of men or fear of womenTrouble trusting others and their motivesFear of intimacy, inability to maintain intimacyFear of abandonment and rejectionTrouble giving and receiving affectionFeeling alienated from othersFear of being used/abusedTrouble saying “no”, taking care of othersTrouble with parentingEntering abusive relationshipsPoor choices of partnersBody SymptomsVague and transient painsMemories of physical painChronic pain or migraine headachesGagging, nausea, vomitingUnpleasant sensation when touchedNegative, distorted body imageSelf-conscious about bodyOverly conscious of appearanceAnger IssuesFear of expressing angerHolding anger inCrying instead of being angryFantasies of revengeFeeling violent, full of rageFear of violenceHomicidal thoughtsAnxiety IssuesEasily startled, inability to relaxFear of being attacked, exposedHypervigilanceFeeling like a frightened childFear of the darkPanic attacks, phobias, agoraphobiaAddiction IssuesAlcohol/drug abuse or dependenceCompulsive spendingIntrusive Thoughts and MemoriesIntense nightmares, unwanted thoughtsFlashbacks: feeling, seeing, smelling, tasting, hearingDetachment IssuesFeeling numb, unrealDisconnected from feelings from bodyFeeling as if there are “personalities” inside“Out-of-body” experiencesControl IssuesFear of authority, rulesNeed to be in control, feeling out of controlPretending to be out of control (or helpless)Fear of being vulnerableAmbivalent about being taken care ofLetting others be in control or trying to control othersAllowing children to be abusedIdentity IssuesConfusion about identity or rolesNegative self-imageNeed to be perfect or perfectly badUnderachievement or overachievementNeed to be totally competentSexual IssuesConcealing sexual feelings, feeling nonsexualDiscomfort with sexual touchingLack of orgasms, sexual dysfunctionsConfusion about sexuality/sexual identityFeeling “dirty”, contaminatedTrading sex for favorsPromiscuity, prostitutionWondering if one is gaySelf-PunishmentSuicidal thoughts, attemptsWanting to die or to be deadSelf-mutilationCompulsive eating or dietingBingeing, purgingOther FeelingsLow self-esteem, guilt, shameFear of feelingsFeeling stuckFeeling like a failureChronic dissatisfactionFrozen emotionsLack of a sense of humorFeeling inadequateFeeling walled in or "crazy"Some evidence has suggested that suicide attempts might have share similar, as well as unique, dynamics asself-mutilation and also might become a chronic pattern or addiction (Mynatt, 2000). Whether or notadolescents have experienced CSA, 4%-38%, use self harming behaviors for stress relief according to U.S.studies (Williams and Bydalek, 2009).Alcohol and drugs are often used to avoid or numb the pain and memories and to bring fleeting pleasure thatis otherwise elusive (Davis and Petretic-Jackson, 2000; Gladstone et al, 2004). Food might also provide briefpleasure or fill emptiness inside (bingeing), but leads to feeling bloated and guilty and a need to purge.Although sex is not usually enjoyable, it can bring relief from loneliness, temporary attention, affection, andapproval. On the other hand, sexual encounters might trigger traumatic flashbacks, anxiety, fear, shame,disgust, or a sense of helplessness. Healthy adult relationships and sexual intimacy are difficult because ofproblems in trusting anyone and the history of linking abuse and love. Victims have boundary issues, troublesetting limits with others, and difficulty with asking for what they really need (Davis and Petretic-Jackson,2000). Victims also tend to be caretakers, rescuers, and co-dependents.Victims’ reactions to the trauma (see Box 41-3) are often labeled as clinical symptoms. In addition, otherproblems resulting from the effects of trauma on the brain may include temporal lobe epilepsy or EEGchanges, autism, and ADHD (Rick and Douglas, 2007), as well as migraines, irritable bowel syndrome, andfibromyalgia (Cassels and Vega, (2007), and chronic fatigue syndrome (Heim, et al, 2009). When an Axis Idiagnosis is given to patients, it is commonly depression (atypical type), PTSD, substance abuse disorder,eating disorder, anxiety disorder, somatoform disorder, dissociative disorder (including dissociative identitydisorder), bipolar disorder, schizophrenia, or impulse-control disorder. Axis II personality disorder diagnosesare commonly borderline, narcissistic, histrionic, avoidant, dependent, atypical, or mixed disorders (Davis andPetretic-Jackson, 2000; Kreidler et al, 2000; Rick and Douglas, 2007).Receiving a diagnosis is a major problem, not only because of the stigma and blaming the victim, but alsobecause the diagnosis often becomes the focus of treatment rather than the underlying issues. This is especiallytrue when the symptoms of CSA are labeled as a diagnosis of borderline personality disorder instead of PTSD(Schwecke, 2009). Lack of appropriate treatment carries a major risk, not only for adult survivors but also fortheir children, especially if the survivors are still in a stage of repression. Evidence has suggested that untreatedor improperly treated victims occasionally set up dysfunctional, disorganized families, in which there isincestuous abuse of the children. With their own denial, repression, amnesia, or other mechanisms, survivorshave trouble relating to their partners and are unable to see the partners’ involvement with their children.Perpetrators (and occasionally victims) might sexually abuse their younger siblings, children, grandchildren,nieces, nephews, and others. Examples of incest have surfaced within three and four generations of a family.Breaking this cycle is of crucial importance.CLINICAL EXAMPLEJan Lester, 30 years of age, was admitted to a psychiatric unit as a result of suicidal ideations and 12 superficial cuts on herwrists. Nine months ago, she began having nightmares about being awakened at night as a child with someone on top of her.During the nightmares, she would wake up crying with strange body sensations, gagging, pressure on her chest, and vaginalpain. As the nightmares and memories became more complete and vivid, she realized her father had frequently had sex withher while her mother was asleep. As her father’s fiftieth birthday approached, she felt as if she could not tolerate going to hisparty. She wanted to be dead but was unable to force herself to cut her wrists more deeply. She wanted help.RECOVERYIn some ways, recovery from childhood sexual abuse or incest is similar to recovery from all crimes and/orfrom PTSD, but it tends to be more complex, difficult, and lengthy by comparison, especially if emotionalabuse by the family is ongoing or if the survivor still lives with the abuser. The memories and emotions arestrong, painful, and confusing. The intense anger and ambivalence toward the perpetrator (because the victimis still seeking approval and love from the perpetrator) are hard for both the survivors and nurse to handle.Survivors need to know in the beginning that the symptoms and emotional pain will probably worsen beforethey improve as the experiences are reviewed. Therefore, survivors need to learn emotionmanagement/regulation to tolerate the distress and use safety measures prior to using imaginal exposuretechniques (Dunbar, 2004; Goodwin, 2005; Spinhoven, et al, 2009). (See the discussion of dialecticalbehavioral therapy [DBT] in Chapter 4 and systematic desensitization in Chapter 38.)Although outpatient counseling often takes 2 years or longer, survivors tend to engage in treatmentsporadically. It is common for survivors to initially disclose, discuss, vent, and feel cured. Then, as new crisesor relationship problems emerge, survivors return to counseling to deal with each issue and its possibleconnection to the original trauma. Getting a patient to commit to continuous, long-term counseling issometimes difficult, but the nurse can emphasize the desirability and value of at least sporadic counseling.The overall goals of recovery are safety and security, rebuilding trust, improved self-esteem and selfacceptance,forgiveness of self, adaptive coping with life and its stresses, assertiveness skills, the capacity forintimate relationships and genuine sexual pleasure, improvements in affect, and reduced anxiety, anger, shame,guilt, fear, and dissociation, as well as the prevention of suicide and sexual abuse of future generations (Davisand Petretic-Jackson, 2000; Kreidler et al, 2000).PUTTING IT ALL TOGETHERPsychotherapeutic ManagementNURSE-PATIENT RELATIONSHIPMuch depends on the nurse’s ability to develop a trusting relationship with the survivor quickly. Empathy,active support, compassion, warmth, and being non-judgemental are crucial. Survivors need to be calmly andmatter of factly asked about childhood sexual abuse, because they are not likely to reveal it spontaneously. Theold and perhaps current coercions to keep the secret remain strong in the minds of survivors; they need to feelsafe about confidentiality and the nurse’s acceptance before disclosure can occur. How much detail is revealedand how soon depends, in part, on the nurse’s ability to be receptive to the experiences without being critical ofthe perpetrator, of other adults in the family, or of the survivor’s loyalty to them. The survivor needs to bereassured that all the experiences and emotions (positive, negative, and ambivalent) are valid and thatexploring them is the beginning of the process of working through recovery (Davis and Petretic-Jackson,2000). It is usually helpful for survivors to be reminded periodically that they were not responsible for and didnot deserve the sexual abuse, are not to be blamed, were not in control of the situation, and that the way theycoped in the past was the best they could do at the time. Cognitive-behavioral approaches and education aboutthe dynamics of sexual abuse and reassurances about recovery can be useful in correcting faulty perceptionsabout the abuse, decreasing self-blame and guilt, and instilling hope for the future despite the inability tochange the past. (See Key Nursing Interventions for Survivors of Childhood Abuse box.)Mentally and emotionally reexperiencing traumatic events (see discussion of imaginal exposure in Chapter38) is disturbing; only periodic, small doses might be tolerable. In contrast excessive rumination on events canbe counter productive (Schwecke, 2009). It is helpful to remind survivors that they went through the abusealone, but do not have to remember it alone. If traumatic flashbacks or dissociation occur, it is important tobring the survivors back to the present by reminding them where they are and that the nurse is with them now.The nurse and survivors can monitor their safety and tolerance of the process to prevent becomingoverwhelmed, retreating, attempting suicide, or self-mutilating. Anger release strategies, such as using a foambat (batacca) while talking to a chair that represents the perpetrator or non-protective adult, often help thesurvivor express thoughts and feelings that could not be expressed in childhood. Play therapy, therapeuticstories, and art therapy can be especially useful in helping children process their abuse (Bennett, 1997; Hinds,1997; Rick and Douglas, 2007). Writing memories and painful feelings in an ongoing journal and writing“letters,” which will not be sent, to the perpetrator and non-protectors can be useful (Cerdorian, 2005).Key Nursing Interventions for Survivors of Childhood Abuse• Contract for safety and control of impulses to harm self or others.• Set limits on self-destructive or self-harm patterns.• Establish a trusting and supportive environment.• Accept all feelings and reactions as normal responses.• Ask permission before touching survivors.• Reinforce that recovery is possible, even if it is difficult.• Educate about the dynamics of abuse and recovery processes.• Assist survivors in understanding current behaviors as reflections of survival strategies used in childhood.• Facilitate re-evaluation of the sexual abuse, its circumstances, and its effects, but without pressuring or excessiverumination.• Encourage coping choices that are in survivors’ best interests.• Discuss safeguarding other children if the perpetrator still poses a risk.• Support choices about future disclosures, confrontation, or reporting.• Be aware that family members and others might feel split loyalty and engage in dysfunctional roles and interaction patterns.• Decrease feelings of isolation, shame, and stigma.• Encourage self-acceptance.• Facilitate acknowledgment, forgiveness, and love for the child within.• Teach and encourage stress management and anger reduction.• Facilitate the transfer of responsibility and anger to the perpetrator but set limits on acting out fantasies of revenge.• Foster separation and individuation from the family and its patterns.• Help to find meaning in the experience and mourning of all the losses (grieving is a very painful experience).• Facilitate the change from victim to survivor status (reexperiencing and integrating the positive, negative, and ambivalentfeelings and memories).• Facilitate reexperiencing and reworking of maturational tasks that were missed or experienced prematurely.• Educate about life skills, communication skills, coping skills, assertiveness, decision making, conflict resolution, boundarysetting, friendship, intimacy, sexuality, and parenting.• Refer to outpatient counseling and appropriate support groups.Confrontation of the family or perpetrator by the survivor is not necessarily a desired outcome or safeoption. Confrontation might be done symbolically or verbally with the nurse and/or in the letters, rather thandirectly with the perpetrator and other family members. If survivors choose to confront directly, muchpreparation is needed before this can happen. Survivors need to consider, plan for, and rehearse their reactionsto all the typical responses of family members, such as denial, rationalization, and blaming the victim.Confessions and apologies are unlikely. (See the family issues box.) Survivors can be helped to debate thebenefits and risks of confrontation, as well as the degree and type of contact they want to have with the family,even if they do not confront them or if the survivors need to protect their own children. An importantconsideration for the nurse and survivor to discuss is the mandatory reporting of child abuse if youngerchildren are currently victims of abuse by the same perpetrators. This type of reporting is understandablydifficult for both the nurse and the survivor, but needs to be carefully and directly addressed.When survivors are in outpatient counseling, it is important to consider priorities in each counseling session.Current crises and problems need to be addressed (instead of the sexual abuse) as they arise. For example,gynecologic and physical examinations might be distressing and trigger flashbacks (Roberts, 2000). Thisaspect is also critical for self-destructive behaviors that are increased because of counseling, such as suicidalideation, self-mutilation, and substance abuse. Hospitalization might be necessary if the crisis is severe. Again,staff should avoid use of restraints that could cause retraumatization (Chandler, 2008). Although survivorsview recovery as frightening and painful, they also experience relief that they are making progress.PSYCHOPHARMACOLOGYMedications are not always needed or desirable for adult survivors of childhood sexual abuse, especially ifsubstance abuse is a problem or potential problem. For the small number of survivors with seriouspsychopathology, medications should be given according to the Axis I diagnosis, such as depression. Anantidepressant such as trazodone (Desyrel) might be used if the depressive symptoms are interfering withsleep. Benzodiazepines or clonidine might be given on a short-term basis to help control the emotional orautonomic arousal that occurs during the reexperiencing of traumatic memories. Occasionally, low doses ofrisperidone (Risperdal) or quetiapine (Seroquel) are given for persistent and severely disturbing nightmares,flashbacks, and/or agitation.MILIEU MANAGEMENTOn an outpatient basis and during any brief hospitalizations, cognitive-behavioral and affect managementgroups can be a useful adjunct to nursing care (Kreidler et al, 2000). If available, a short-term or ongoingsexual abuse or incest recovery group is beneficial. Some self-help groups include Incest SurvivorsAnonymous, Survivors of Sexual Abuse, and Daughters and Sons United. Parents United (for thenonperpetrator parent) can be suggested, if appropriate. The perpetrator might also be referred to counseling.Family therapy is sometimes appropriate.Other groups that might be recommended, depending on the symptoms and needs of the survivor, are CodependencyAnonymous, Adult Children of Alcoholics, Alcoholics or Narcotics Anonymous, and EmotionsAnonymous. Survivors might also be directed to classes or short-term groups that address issues such asdecision making, problem solving, communication or relationship skills, conflict resolution, angermanagement, parenting skills, and human sexuality.1CRITICAL THINKING QUESTIONYou are working with a patient who was sexually abused as a child by her father. The father insists on visiting his daughterand telling you about her history of emotional problems and lying about the family. What is your approach in working withthe father?PARTNER AND ELDER ABUSENATURE OF THE PROBLEMEstimates are that more than 7% to 21% of men and women have suffered physical assault by a partner in thepast year. In a national survey, young adults reported violence in the past year toward an intimate at 35% forwomen (often in self defence) and 37% in men (Carretta 2008; Gratz, et al, 2009). The number is even higherwhen psychological abuse and other violations of rights are considered (Figure 41-1; Daniels, 2005; Duttonand Nicholls, 2005). It is difficult to collect statistics on female to female, female to male, and male to maleabuse because of the lack of reporting (Brown, 2008; Dutton and Nicholls, 2005). Women are abused, raped,tortured, or beaten by their husband, boyfriend or girlfriend, male or female lover, former partner, or estrangedpartner (Carretta, 2008; Daniels, 2005), and most of this abuse goes unreported, even when injuries are severeenough to require treatment. Prior partner abuse increases the risk of it occurring during pregnancy (Tilley andBrackley, 2004). In primary care practice, it has been estimated that 34% to 46% of the female patients arevictims of partner abuse (Lie and Barclay, 2005b).Dating violence in the adolescent population is estimated to be 10% to 35%. Up to 20% of children (ages11-14) are being affected as they get into emotional and sexual dating relationships (Surprising New Research,2008). Contributing factors for these children include witnessing parental violence, prior victimization orabuse, earlier puberty, typical stresses and issues of early adolescence, earlier use of drugs and alcohol, andexposure to media violence (Close, 2005; Gratz, et al, 2009; Miller, 2004)."Finally, among older adults, sexual, physical, and psychological abuses exist as well as forced suicide orhomicide of widows for economic reasons" (Carretta, 2008). Elder abuse also includes violation of personalrights, abandonment, and material and financial exploitation (Baker, 2007). It is estimated that 3.2% of thoseaged 65 and older are abused while they still live in a private home, but only 1 in 5 are probably reported(Baker, 2007).Family Issues: False Memories? False Allegations?Some families, including members of the False Memory Syndrome Foundation, claim that they have been wrongly accused ofsexual abuse by their children or adult children. These families and some professionals especially challenge the validity of theprocesses of repression and delayed recovery of memories of abuse. They warn that those who interview children, those whocounsel children and adults, and members of support groups can implant false memories and provide support for false allegations.These families and professionals question the credentials and training of many who counsel children and adults who claim thatthey were abused. They cite studies of recent and long-term memory to support their views about distorted and false memories.They sometimes question the claims of serious emotional damage to victims as a result of actual sexual abuse. They support thepremise that false memories and false allegations are destroying the families of these children. At the same time, the NorthAmerican Man Boy Love Association (NAMBLA) wants legislation that permits sex between boys and men.Other professionals and adult survivors of childhood sexual abuse maintain that the graphic details of children’s traumaticmemories and the use of sexual descriptions, very advanced for their age at the time, support the credibility of the abuse charges.These professionals and survivors claim that denial, repression, amnesia, and dissociation are real and are used by children,adolescents, and adults to protect themselves emotionally from the abuse as it was happening and from the later realization of itsmoral, legal, ethical, and emotional significance. These individuals maintain that 75% or more of survivors are able to collectstrong corroborating evidence of their abuse and recovered memories. They cite recent neurochemical studies of traumaticmemory processes, stress, and PTSD (see Chapter 31) to support their view of the validity of repression, dissociation, andrecovered memories. They acknowledge that 2% to 10% of claims of sexual abuse by children and divorcing parents might befalse, but report that perhaps 75% to 90% of valid child abuse is never reported by children, agencies, and professionals. Theypoint out that the False Memory Syndrome Foundation admits that it collects only information on denials of charges of abuse buthas no way of knowing if these denials are true or false. Survivors and professionals contend that those who molest childrentypically threaten the victims to “keep the secret” and use denial, minimization, and rationalization when charged with abuse.They also express concern that claims of false memories and false allegations are efforts to disconfirm and “blame the victim,”protect abusers (and society), and minimize the severity of the short- and long-term effects of abuse. They contend that familiesare being destroyed by interfamilial violence (not the reports of abuse) and that abused children suffer emotional pain and a widevariety of problems throughout childhood, adolescence, and adulthood.As a result of this controversy, it is recommended that those working with possible survivors of childhood sexual abuse do thefollowing:1. Allow patients’ memories to emerge without pressure and leading questions.2. Avoid specific sexual abuse explanations for patients’ symptoms.3. Follow established guidelines for interviewing child victims and others to assess the credibility of memories and testimony.4. Interview anyone who might provide corroboration or disconfirming evidence.5. Use established therapeutic techniques rather than nonestablished methods.6. Avoid using hypnosis and sodium amytal injections as a way of recovering repressed memories.Modified from Gardner RA: True and false accusations of child sex abuse, New York, 1992; Leavitt F: Iatrogenic memory change:examining the empirical evidence, Forensic Psychology 19:21, 2001; Loftus EF, Potage DC: Repressed memories: when are they real?Psychiatr Clin North Am 22:61, 1999; Valente S: Controversies and challenges of ritual abuse, J Psychosoc Nurs 38:8, 2000; Satel SL:Who needs trauma initiatives? Psychiatr Serv 52:815, 2001; van der Kolk B, McFarlane AC, Weissaeth L: Traumatic stress: the effectsof overwhelming experience on mind, body, and society, New York, 1996, Guilford Press; Anorexia Nervosa and Associated Disorders(Indianapolis Chapter of National ANAD): Personal interviews, Indianapolis, 2002, ANAD; Katchen MH: Ritual abuse vs. religiousabuse: the development of an artificial distinction, MKzine 3:9, 2005; Shea DJ: Effects of sexual abuse by catholic priests on adultsvictimized as children, Sexual Addiction & Compulsivity 15:250, 2008.Partner abuse victims tend to conceal their victimization. They are acutely aware that disclosure of theirplight will be met with denial or be minimized by the partner, friends, and relatives and by increased abuse bytheir partners (Merrell, 2001). As abused women become more independent (both emotionally and financially),the incidence of violence by their partners increases as well. The fact that 30% to 50% of all women killed inthe United States are killed by a partner as they tried to leave or had left supports women’s fears (Carretta,2008; ; Jordan, 2004; Logan and Walker, 2004). About 50% of victims murdered by partners were seen in theemergency departments for injuries at other times before they died (Gerard, 2000). Men are also killed by theirpartners (4% of all male homicides) (Carretta, 2998; Daniels, 2005). Homicide occurs, sometimes in selfdefenseduring the abuse or after a history of beatings.Studies have shown that partner abuse crosses all social, racial, cultural, and economic classes, includingboth homosexual and heterosexual relationships, but is more often reported by individuals on welfare. Thistendency is because the victims are more likely to be in contact with reporting agencies, such as public healthnurses, welfare offices, public clinics, and emergency rooms. Individuals with higher incomes are likely toobtain private services that do not report the abuse (Poirier, 2000). Nurses in any setting need to screen patientsfor any past or current abuse (Lewis-O’Connor, 2004).The relationship of alcohol and drug abuse to violent behavior has been the subject of many studies onpartner abuse. Some abusers are abstainers, but more are substance abusers (Murphy et al, 2005). The victim’sview is that the abuser uses alcohol and drugs as an excuse for their violence and drink when they are about tobecome violent. Victims have also reported a correlation between increased intake of alcohol and the severityof violence (Murphy et al, 2005). The combination of substance abuse and violence encourages victims toblame the substance rather than hold the batterers accountable for their violent behaviors. Women oftendescribe their abusers as Dr. Jekyll and Mr. Hyde, with changing personalities—gentle, loving, and kind attimes; rude, uncaring, and violent at other times. This change is explained, in part, by the cycle of violencedescribed later.In some relationships, violence is mutual (Dutton and Nicholls, 2005; Whitaker, 2007) and is the result ofefforts to resolve negative communications and escalating conflicts. These couples are often motivated tochange and can be taught more effective skills for handling conflict and anger. This mutual violence patterndiffers from, but can become, the more common pattern of using violence to exploit and control a partner,often arising out of anger, fear of abandonment, and jealousy (McClellan and Killeen, 2000). This secondpattern almost always involves a man abusing a woman, and the man has little motivation to change. Separateinterventions and therapy with the man, such as motivational interviewing, might interrupt the cycle ofviolence (Alexander and Morris, 2008). Other studies have reported that men and women use violence almostequally in the non mutual abuse pattern and those with Axis II personality disorders have somewhat higherrates of violence with their partners (Dutton and Nicholls, 2005).The nature of modern society is a factor to be considered in partner abuse. The portrayal of physical andsexual violence in the media (e.g., the Internet, television, music videos, and films) continues to increase infrequency and severity. Women are still portrayed by the media as second-class citizens at times. However,women younger than 30 are more aggressive in their intimate relationships than women older than 30 (Duttonand Nicholls, 2005). In addition, it is well documented that witnesses of family violence and victims of childabuse and neglect tend to become perpetrators of other violence or the abusers and partners of abusers (Hilland Nathan, 2008; Stith, et al, 2004; Woods and Wineman, 2004).In elder abuse and neglect, 90% of the perpetrators are family members, especially adult children andspouses. Other relatives, grandchildren, friends, neighbors and home service providers may be abusive orneglectful (Baker, 2007). Unfortunately elder abuse, sexual abuse, and neglect also occur in long term carefacilities by staff and other residents (Ramsey- Klawsnik, et al, 2007). Elder abuse shows similar power andcontrol dynamics (Box 41-5) as dies partner abuse (Spangler and Brandl, 2007).EFFECTSMost experts acknowledge the development of learned helplessness, hopelessness, isolation, and resignation inresponse to ongoing emotional and physical abuse. Abused women report that they fear and hate the abuse, buthave a tendency to believe their partner’s view that they deserve the abuse. Box 41-4 presents common reasonswhy women endure long-term abuse. Another accepted view of why women endure abuse is the cycle ofviolence (Box 41-5). During the honeymoon stage, the good side of the man is evident, and the woman isreminded of their love and the happy potential of the relationship (Farella, 2000; Gerard, 2000; Walker, 1979).Women report thinking that they can help their partners overcome their problems and violent behaviors. Thereis still a shortage of safe places to go, as well as a shortage of services to help victims become independent.Many states still have ineffective or outdated laws that indirectly perpetuate abuse rather than foster arrest ofthe abuser for assault and battery. Arrest is a way that batterers get the message that their violence is a crimeand not their right (Jordan, 2004; Williams, 2005).Box 41-4Why Women Stay as Long as They DoSituational Factors• Economic dependence; lack of job skills• Fear of greater physical danger to themselves and their children if they attempt to leave or have partner arrested• Fear of emotional damage to children because of being without a father• Fear of losing custody of children• Lack of alternative housing• Social isolation; lack of support from family or friends• Lack of information regarding alternatives• Fear of involvement in court processes• Fear of retaliation from partner or partner’s familyEmotional Factors• Poor self-image; fear of being alone• Being in a state of denial and living a secret• Personal embarrassment and protecting the image of husband and family• Insecurity over potential independence and lack of emotional support• Guilt about failure of marriage or relationship• Fear that partner is not able to survive alone• Belief that partner is sick and needs her help• Belief that partner will change• Ambivalence and fear about making formidable life changes and having increased responsibilityCultural Factors• Knowing that batterers are not held accountable for their violent actions• Believing that the abuse is her fault• Being raised to be passive and submissive• Developing survival skills instead of escape skills• Recognizing that the legal system is a male-dominated systemPlus: She Still Loves HimModified from Julian Center Shelter, Indianapolis ,IN, and Task Force on Families in Crisis, Nashville, TN.Battered woman syndrome has been suggested as a sub-classification of PTSD because repetitive abuse is aserious threat to the victim’s health and life. Victims often report nightmares, flashbacks, recurrent fears ofmore violence, emotional detachment, numbness, startle response, sleep problems, guilt, impairedconcentration, and hypervigilance. However, there are other symptoms, such as depression, hostility, low selfesteem,self-blame, relative passivity, impaired decision making, psychosomatic complaints, fatalism, socialisolation, and an unwillingness to seek help (ANAD, 2002; Carretta, 2008; Logan and Walker, 2004). As withPTSD, battered women show typical reactions to a chronic trauma, not symptoms of psychopathology.Labeling and blaming the victims again shifts responsibility away from the perpetrators.Box 41-5 Cycle of ViolenceManI. Tension buildingHe has excessively high expectations of her.He blames her for anything that goes wrong.He does not try to control his behaviors.He is aware of his inappropriate behaviors but does not admit it.Verbal and minor physical abuse increase.Afraid that she will leave, he gets more possessive to keep her captive.He gets frantic and more controlling.He misinterprets her withdrawal as rejection.II. Serious battering incidentThe trigger event is an internal or external event or substance.The battering usually occurs in private.He will threaten more harm if she tries to get help (police, medical).He tries to justify his behaviors but does not understand what happens.He minimizes the severity of the abuse.His stress is relieved.III. HoneymoonHe is loving, charming, begging for forgiveness, making promises.He truly believes that he will never abuse again.He feels that he taught her a lesson and she will not act up again.He preys on her guilt to keep her trapped.WomanI. Tension buildingShe is nurturing, compliant, and tries to please him.She denies the seriousness of their problems.She feels she can control his behaviors.She tries to alter his behavior to stay safe.She tries to prevent his anger.She blames external factors: alcohol, work.She takes minor abuse, but does not feel she deserves it.She gets scared and tries to hide (withdrawal).She might call for help as the tension becomes unbearable.II. Serious battering incidentIn cases of long-term battering, she might provoke it just to get it over with.She might call for help if she is afraid of being killed.Her initial reaction is shock, disbelief, and denial.Fearing more abuse if police come, she might plead for them not to arrest him.She is anxious, ashamed, humiliated, sleepless, fatigued, depressed.She does not seek help for injuries for a day or more and lies about the cause of injuries.III. HoneymoonShe sees his loving behaviors as the real person and tries to make up.She wants to believe that the abuse will never happen again.She feels that if she stays, he will get help; the thought of leaving makes her feel guilty.She believes in the permanency of the relationship and gets trapped.Modified from Walker L: The battered woman, New York, 1979, Harper & Row; Gerard M: Domestic violence: how to screen and intervene, RN63:52, 2000; McFarlane J, Malecha A, Gist J, et al: Increasing the safety promoting behaviors of abused women, Am J Nurs 104:40, 2004.According to victims, it is unlikely that abused women will leave their partners until they realize that thecycle is not going to stop and they have the emotional support to leave and a safe place to go. Fearing that thenext beating might be fatal, finding that their partners are physically or sexually abusing their children, andrealizing that their children are learning to be abusive are incentives for leaving permanently (ANAD, 2002;Miller, 2004).RECOVERYImmediately preceding or at the beginning of a serious battering incident, victims are frightened, amenable tocrisis intervention, and more likely to call the police or a crisis service agency for help. Getting victims andtheir children to a shelter or other safe place, if they will go, are desirable when immediate danger of injury ispresent. If injuries have occurred, victims should be encouraged to go to an emergency department. In anycase, crisis workers, shelter workers, or nurses can begin the important process of assessment and providinginformation that can make a dent in the cycle of abuse. Even if the survivors are not yet ready to leave theirpartners, they can be given an easily concealed card with telephone numbers of police, prosecutors, crisisservices, victims’ assistance, shelters, and support groups, and perhaps a short message about the inevitabilityof the cycle of violence and the fact that no one deserves to be abused. If contact is only by phone or if they areworried that the abusers will find the card, they can be asked to write down the phone numbers on the back of apicture in their wallets or be told to call 911. (In some cities, such as Indianapolis, dialing 211 provides a directconnection to the Domestic Violence Network.) Survivors can also be given ideas for developing a safety orescape plan (Daniels, 2005), such as packing a bag with medicines and clothes for them and their children,house and car keys, money and change for the pay telephone (if they don’t have a cell phone), and importantphone numbers and papers (e.g., bank account numbers, birth certificates, social security numbers, medicalinsurance cards, no contact/protective orders). They should also be informed of the protections afforded bylegal statutes, protective orders, and more recent antistalking laws. Also keep in mind that in elderabuse/neglect situations, all states have mandatory reporting laws and procedures and the survivors need toknow this. These affect confidentiality and may pose more safety issues. Adult protective and advocacyservices and the judicial system are essential resources (Spangler and Brandl, 2007). Long-term goals forsurvivors of partner abuse are to develop self-confidence, self-respect, independence, healthy support systems,and a sense of freedom, safety, and empowerment.PUTTING IT ALL TOGETHERPsychotherapeutic ManagementNURSE-PATIENT RELATIONSHIPBecause most abused women seek help for their injuries and somatic symptoms at least once, nurses can beinstrumental in offering information and assistance. Nurses in emergency departments, clinics, physicians’offices, and community health agencies need to know how to recognize a survivor, make an assessment, offersupport and make a referral to available services (Carretta, 2008). Some common cues to abuse are listed inBox 41-6. In the elderly, there also may be malnutrition, frailty, immune suppression, pressure ulcers, andearly mortality (Baker, 2007). Inadequate provision of safety, clothes, shelter, food, water, hygiene,medications, glasses, hearing sides, dentures, and comfort are also common (Alexander and Fulmer, 2007).The assessment process is often difficult because survivors fear disclosure, are embarrassed about the situation,desire to be treated quickly and leave, and sometimes the abusers are present. It is important to interview thevictim privately and with sensitivity, empathy, and compassion. Box 41-7 describes other responses thatsurvivors consider helpful.The most crucial information to document in an initial contact is the following:1. Identity and current location of the abuser2. Location and safety of any children3. Length and frequency of abuse4. Types of abuse (physical, psychological, sexual, financial) and use of weapons5. Types and locations of injuries (photographs and body maps are preferred)6. Availability of weapons at the place of residence7. Use and abuse of substances and medications by victim and abuser8. Active and passive suicidal ideations (with or without a plan or a wish to be dead)9. Types of service desired (police, legal, shelter, crisis counseling, knowledgeable clergy, social serviceagencies, and transportation)10. Referrals madeBox 41-6Common Cues to Partner Abuse• Repeated, vague symptoms or illnesses that are not confirmed by tests, such as backache, abdominal pain, indigestion, headaches,hyperventilation, anxiety, insomnia, fatigue, anorexia, heart palpitations• Unexplained injuries or ones with unlikely explanations and embarrassment about them• Hidden injuries such as those in areas concealed by clothes or visible on physical or x-ray examination only—for example, head andneck injuries, internal injuries, genital injuries, scars, burns, joint pain or dislocations, numbness, hearing problems, or bald spots• Injuries with recognizable marks such as those from a belt, iron, raised ring, teeth, fingertips, cigarette, gun, or knife• Multiple fractures or bruises in various stages of healing• Jumpiness or flinching in the presence of the abuser• Substance abuse and suicidal thoughts or attempts• Attempts to conceal fear of the abuser• Continual efforts to keep the abuser from getting angry• Denial of any problems in the relationship• Lack of relationships with family or friends• Isolation or confinement to home• Guilt, depression, anxiety, low self-esteem, sense of failure, concealed anger• Continual justification of own actions and whereabouts of the abuser• Continual justification of the abuser’s actions in public; excusing or rationalizing the behaviors• Believing in family unity at all costs and in traditional stereotypes• Believing in managing alone, even when help is offered• An over solicitous abuser who does not want to leave the victim alone with hospital or agency staff or even with family and friendsModified from Constantine RE, Bricker PL: Social support, stress, and depression among battered women in the judicial setting, J Am PsychiatrNurses Assoc 3:81, 1997; Merrell J: Social support for victims of domestic violence, J Psychosoc Nurs 39:31, 2001; Miller MC: Counteringdomestic violence, Harv Ment Health Lett 20:1, 2004; Carretta CM: Domestic violence: A world wide exploitation, J Psychosoc Nurs 46:3, 2008.Even if the initial contact is brief, it is important to convey to survivors that they are not alone in their abuseand that there are those who are willing and able to help when they are ready. Survivors also need to be toldmore than once that they do not deserve the abuse. The nurse must convey to survivors that they are importantand have dignity and worth. They need acknowledgment of their mental and physical exhaustion, fears, andambivalence about the abuser, leaving, and their wish to help the abuser, as well as themselves. It is difficultfor nurses and all professionals to accept that survivors cannot be pushed, rushed, or coerced into leaving theabuser before they are ready. In fact, survivors might want to try couples/family counseling and even personalcounseling (when the abuser refuses counseling) more than once before giving up hope of saving therelationship and of helping the ones they love. It is important to recognize and to acknowledge that it iscommon for survivors to leave and return several times; it is a process, not a single event (Leone, Johnson,Coban, 2007; Spangler and Brandl, 2007). Survivors need not feel guilty or ashamed for trying to improve therelationship. In fact, the guilt of leaving will be lessened if they believe they have tried everything and arefinally able to acknowledge that nothing will change, because the abusers are the only ones who can controlthe violence and stop the abuse.Box 41-7Helpful Responses to Partner/ Elder Abuse• Be non-judgemental, objective, and nonthreatening.• Ask directly if abuse is occurring.• Identify the abuser’s behavior as abusive.• Acknowledge the seriousness of the abuse.• Assist the victim in assessing internal strengths.• Encourage the use of personal resources.• Give the victim a list of resources: shelters, financial aid, police, and legal assistance.• Allow victim to choose own options.• Offer names of relevant support groups.• Help victim to develop a safety or escape plan.• Tell the abuser to stop the abuse and get help.• Do not disbelieve or blame the victim.• Do not get angry with the victim.• Do not refuse to help if the victim is not ready to leave the abuser.• Do not align with the abuser against the victim.• Do not push the victim to leave the abuser before ready.When an abused woman does leave her partner, the problems are not over. Box 41-8 describes some of thecommon reactions the abuser might have and ways in which he might behave. Psychological and physicalabuse might continue after separation (Logan and Walker, 2004). Survivors frequently need longer termcounseling and social services to recover and become independent, especially if the abuser is unwilling toparticipate in couples’ counseling or an abusers’ program (often a court-ordered program of group educationand counseling lasting 26 weeks or longer). Nursing interventions for survivors (individually or in groups,using cognitive-behavioral techniques) generally focus on the following:Box 41-8If You Have Left an Abusive Man...1. Your problems are not over.2. Your abuser will try to locate you through family and friends. He will play on their sympathy or intimidate them.3. He will repeatedly apologize, make promises about changing, and give gifts.4. Next, he will threaten or intimidate you, your children, family, and/or friends.5. He might threaten to kill himself because of you.6. He often threatens to take your children away.7. In another step, he will enter counseling and/or will express religious fervor.8. He might try to find a counselor or religious leader to try to convince you to return to him.9. Next, he might harass and stalk (begging, crying, phone calls, written or verbal threats, legal actions, or following you from locationto location).Regardless of his tactics, take advantage of legal, community, and personal resources to protect yourself and your children.Modified from the Salvation Army Domestic Violence Program, Indianapolis, IN.1. Monitoring safety from partner abuse and preventing suicide2. Reiterating information about abuse, the cycle of violence, and the abuser’s accountability3. Building self-esteem, confidence, independence, and sense of hope4. Sharing of feelings, especially anger, frustration, fear, and anxiety5. Decreasing shame, guilt, embarrassment, manipulation, and isolation6. Confirming personal rights, as well as legal rights7. Teaching stress management techniques8. Teaching communication techniques9. Teaching conflict resolution techniques10. Teaching assertiveness training11. Teaching parenting techniques12. Decreasing co-dependency behaviors13. Building a new, improved support system14. Setting goals and specific plans for immediate future15. Resolving griefReferrals might also be needed for job counseling or training, legal assistance, financial aid, child care, andpermanent housing. At any stage during working with survivors, brief hospitalization might be needed becauseof injuries, suicide attempts, self-mutilation, or substance abuse and for treatment of serious problems such asdepression, anxiety, or panic attacks. Assessment and treatment for ongoing headaches, gastrointestinalcomplaints, back and pelvic pain, hyperventilation or chest pains, and insomnia is also needed (Amar andClements, 2009).2CRITICAL THINKING QUESTIONYour co-worker is sharing with you that she is thinking about leaving her husband because of his drinking and long-termemotional abuse of her. She expresses a fear that he might try to kill her and a fear of raising her two children alone. Whatinformation would you offer her?PSYCHOPHARMACOLOGYMedications normally are not needed but are commonly given to survivors. Often misprescribed medicationsare antidepressants, benzodiazepines, and hypnotics. These same medications might be used appropriately ifthe survivor’s symptoms of depression, anxiety, sleeplessness, or nightmares or flashbacks are severe.Continual assessment is needed to determine when medications are no longer needed to prevent abuse andaddiction.MILIEU MANAGEMENTGroups in inpatient or outpatient settings that might be relevant for survivors are those focusing on selfesteem,problem solving, assertiveness, relationship issues, stress management, and co-dependency. Substanceabuse groups should be recommended, if necessary. In the community, a group for abused women is desirable.One form of intervention is a telephone support program that focuses on safety-promoting behaviors. Six callsover 8 weeks have encouraged increased use of these behaviors, which were more likely to be practiced even18 months later (McFarlane et al, 2004). The National Domestic Violence Hotline is also available (800-799-SAFE) and online (www.ndvh.org) (Phillips, 2008).3CRITICAL THINKING QUESTIONAs an emergency room nurse, you are treating a 19-year-old male victim who was tortured and raped by a local gang. Thevictim refuses to give any details or to identify members of the gang. Describe what information you would give him aboutbeing a victim and the benefits of follow-up counseling.Study Notes1. Not all crimes involve physical violence and injury; however, all crimes involve emotional violation andinjury. Victims lose a sense of the ability to control their own lives, as well as losing trust in others.2. Progression through the stages of recovery from a crime might take years. Crisis intervention and groupmeetings with other survivors can facilitate recovery.3. In assisting survivors, sensitivity to their needs is crucial to build trust and to avoid blaming the victim.4. Information about counseling resources and support groups can be given to the survivors of any crime ortrauma for later use, even if there is an initial denial of the need for help.5. The reexperiencing and working through of any trauma/crime memories is a painful, lengthy, andsometimes sporadic process that requires intense support and empathy.6. Adult survivors of childhood sexual abuse might repress memories for years as a result of the emotionalturmoil and sense of being betrayed by the abuser and others.7. Adult survivors of childhood sexual abuse typically enter counseling for a variety of overt problems,unaware of how these are related to childhood trauma.CASE STUDYRachael Benton, a 26-year-old survivor of incest by her father, is married to Richard. She has an 8-year-old child, Matthew;Richard has three boys, Robert, James, and Daniel, ages 11, 8, and 7, who live with them. Angela, age 5, was born after Rachaeland Richard were married. Matthew was removed from the home after being abused by Robert. Rachael sought help by attendinga battered women’s group.Rachael’s situation was difficult to resolve. Because of heavy drinking, Richard was missing work and changing jobs. Hisincome declined and was sporadic but expenses did not decline. Without insurance, Rachael’s repeated treatment of menstrualirregularities, back pain, chronic and severe headaches, and diarrhea were not paid for. She avoided treatment for bruises, asuperficial knife wound, head cuts, and contusions. Richard repeatedly punched her stomach during a pregnancy, causing amiscarriage.It was when Richard raped her that Rachael realized that there was no hope for change and that she had to leave. As Rachaelbecame more assertive and independent, Richard demanded that she stay home, bought a shotgun to convince her to stay, andtook the starter off the car. He rode to work with co-workers. Rachael had not adopted Richard’s boys, so she could not take themwith her. She was afraid that his verbal abuse of them would turn to physical violence when she left. Richard knew about all theplaces she thought of going.It took 4 months to develop, coordinate, and implement arrangements so that Rachael and Angela were safe in leavingRichard. Neighbors, friends, and teachers were warned of the potential abuse of the boys and given the phone number foranonymously reporting child abuse. Rachael’s mother rented her a small trailer in a rural town and obtained forms for Aid toFamilies with Dependent Children. Rachael secretly and gradually packed clothes and important documents in the trunk of agroup member’s car.One night (14 months after the group began) Richard got drunk, beat Rachael, and tried to rape her again. She fought him offand waited until he passed out. The group member with the packed car drove her to the new trailer. As expected, Richard got hisshotgun and went to every friend of Rachael’s, but none knew where she was. He drove to Rachael’s mother’s home, and shecalled the sheriff when his car pulled into the driveway. Richard was escorted out of the county and warned not to return. Withina week, Daniel’s teacher filed a child abuse report about bruises found on him. Within 2 weeks, the boys were removed from thehome and returned to their natural mother.Rachael has received proper medical treatment and feels healthier. She is now divorced, going through a job training program,and maintaining her secret location. She feels safe but is still in counseling once a month to complete her emotional recovery. Sheattends a support group for battered women once a week.Care PlanName: Rachael Benton Admission Date:___________________DSM-IV-TR Diagnosis: Physical abuse of an adult by partnerAssessment Areas of strength:Bright, articulate, and capable of problem solving; mother and one friend willing to help;developing trust in group and beginning to process her feelings and rights.Problems:Lack of safe housing and employment; inability to remove husband’s children from the houseand fear he will abuse them; fear of increased abuse of her, even death, if she tries to leave;severe headaches.Diagnoses • Decisional conflict related to dysfunctional marriage, as evidenced by attendance in a batteredwomen’s support group.• Posttrauma syndrome related to previous sexual abuse and physical, emotional, and economicabuse, as evidenced by physical wounds, fear, and emotional trauma.• Fear (of leaving husband) related to potential abuse of sons, as evidenced by reluctance to leavewithout stepsons.Outcomes Short-term goals: Date met• Patient will remove bullets from gun; design an escape plan. ____________________• Patient will verbalize ability to survive on her own; confirm ____________________Housing in rural county.Long-term goals:• Patient will enroll in job training program. ____________________• Patient will obtain legal assistance for divorce. ____________________• Patient will seek medical treatment for chronic problems. ____________________Planning/ Nurse-patient relationship: Listen nonjudgmentally and empathically; accept strangeInterventions behaviors related to secrecy and self-protection; avoid disparaging spouse and pressuring to leave;locate resources for training, finances, counseling, and medical care in rural county.Psychopharmacology:Desyrel, 50mg at bedtime, to alleviate moderate depression and improve sleep; ibuprofen prn forsevere headaches.Milieu management:Encourage continuing in local support group; locate support group in rural county; continueassessment of safety of patient and children.Evaluation Patient has moved to rural county and joined support group; is receiving counseling and medicalcare. Husband’s children were removed and placed with natural mother.Referrals Has an appointment with a job training program in the rural county.8. The concepts of learned helplessness, the cycle of violence, and other situational, emotional, and culturalfactors help explain why survivors often remain with their abusive partners.9. Immediately preceding or at the beginning of a serious battering incident is when abuse victims are mostamenable to crisis intervention and referrals for needed services.10. Patience, support, and information are critical aspects of nursing interventions with all survivors.ReferencesAi AL, Cascio T, Santangelo LK, Evans-Campbell T: Hope, meaning, and growth following the September 11, 2001, terrorist attacks, J InterpersViolence 20:523, 2005.Alexander PC, Morris E: Stages of change in batterers and their response to treatment, Violence and Victims 23:4, 2008.Alexy EM, Burgess AW, Prentky RA: Pornography use as a risk marker for an aggressive pattern of behavior among sexually reactive childrenand adolescents, J Am Psychiatr Nurs Assoc 14:6, 2009.Alim TN, Feder A, Graves RE, Wang Y, Weaver J, et al: Trauma, resilience, and recovery in high-risk african-american population, Am JPsychiatry 165:12, 2008.Amar AF: Behaviors that college women label as stalking or harassment, J Am Psychiatr Nurs Assoc 13:4, 2007.Amar AF, Clements PT: The intersection of violence, crime, and mental health, J Am Psychiatr Nurs Assoc 14:6, 2009.Anorexia Nervosa and Associated Disorders (Indianapolis Chapter of ANAD): Personal interviews, Indianapolis, 2002, ANAD.APNA: APNA 2008 position statement: Workplace violence executive summary, American Psychiatric Nurses Association, 2008.Baker MW: Elder mistreatment: Risk, vulnerability, and early mortality, J Am Psychiatr Nurs Assoc 12:6, 2007.Baliko B, Tuck I: Perception of survivors of loss by homicide: Opportunities for nursing practice, J Psychosoc Nurs 46:5, 2008.Bennett L: Projective methods in caring for sexually abused young people, J Psychosoc Nurs Ment Health Serv 35:18, 1997.Brown C: Gender-role implications on same-sex intimate partner abuse, J Fam Viol 23:457, 2008.Brown K: Rape and sexual assault: the nursing role, Nurs Spectrum (Metro Edition) 29, August, 29, 2001.Burgess AW, Brown K, Bell K, et al: Sexual abuse of older adults, Am J Nurs 105:66, 2005.Burgess AW, Mahoney M, Visk J, Morganbesser L: Cyber Child sexual exploitation, J Psychosoc Nurs 46:9, 2008.Campbell R, Wasco SM: Understanding rape and sexual assault, J Interpers Violence 20:127, 2005.Carretta CM: Domestic violence: A worldwide exploration, J Psychosoc Nurs 46:3, 2008.Cassels C, Vega C: Childhood abuse linked to migraine with major depression, Available at Medscape http://www.medscape.com/viewarticle/562572_print. Accessed 9/14/2007.Center for American Nurses, The center for american nurses calls for an end to lateral violence and bullying in nursing work environments,February 27, 2008.Cerdorian K: The needs of adolescent girls who self-harm, J Psychosoc Nurs Mental Health Serv 43:40, 2005.Chandler G: From traditional inpatient to trauma-informed treatment: Transferring control from staff to patient, J Amer Nurses Assoc 14:5, 2008.Close SM: Dating violence in middle school and high school youth, J Child Adol Psychiatr Nurs 18:2, 2005.Cole H: Human trafficking: Implications for the role of the advanced practice forensic nurse, Am Psych Nurses Assoc 14:6, 2009.Cook LJ: The ultimate deception: childhood sexual abuse in the church, J Psychosoc Nurs 43:19, 2005.Courey YJ, Marttsolf DS, Draucker CB, Strickland KB: Hildegard Peplau's theory and the health care encounters of survivors of sexual violenceJ Am Psychiatr Nurses Assoc 14:2, 2008.Daniels K: Violence and depression: a deadly comorbidity, J Psychosoc Nurs 43:45, 2005.Davis JL, Petretic-Jackson PA: The impact of child sexual abuse on adult interpersonal functions: a review and synthesis of the empiricalliterature, Aggression Violent Behav 5:291, 2000.Dietz TW: Coping beyond the CISM response: Practical approaches for reframing traumatic events, LifeNet 18:4, 2007.Dowbecko U: “The Manchurian Candidate”: all-American conspiracy, MKzine 3:5, 2005.Dunbar B: Anger management: a holistic approach, J Am Psychiatr Nurses Assoc 10:16, 2004.Dutton DG, Nicholls TL: The gender paradigm in domestic violence research and theory: part I—the conflict of theory and data, AggressionViolent Behav 10:680, 2005.DiVasto P: Measuring the aftermath of rape, J Psychosoc Nurs Ment Health Serv 23:33, 1985.Farella C: Hot and bothering: sexual harassment in the workplace is no joke, Nurs Spectrum (Metro Edition) September 14, 2001.Farella C: Love shouldn’t hurt: understanding domestic violence, Nurs Spectrum (Metro Edition) November: 2000.Faravelli C, Giugni A, Salvatori S, Ricca V: Psychopathology after rape, Am J Psychiatry 161:1483, 2004.Foa EB: The psychological aftermath of Hurricane Katrina, Medscape Psychiatry Ment Health 8:1, 2005.Gates D: Burgers or bruises? Being assaulted shouldn’t be part of a nurse’s aide’s job, Am J Nurs 104:13, 2004.Gerard M: Domestic violence: how to screen and intervene, RN 63:52, 2000.Girardin B: Is this forensic specialty for you? RN 64:37, 2001.Gladstone GL, Parker GB, Mitchell PB, et al: Implications of childhood trauma for depressed women, Am J Psychiatry 161:1417, 2004.Goodwin JM: Redefining borderline syndromes as posttraumatic and rediscovering emotional containment as a first stage in treatment, JInterpers Violence 20:20, 2005.Gratz KL, Paulson A, Jakupcak M Tull MT: Exploring the relationship between childhood maltreatment and intimate partner abuse: Genderdifferences in the mediating role of emotion dysregulation, Violence and Victims 24:1, 2009.Hader R: Workplace violence: Survey 2008, Nursing Management, July, 2008.Miller L: Workplace violence: practical policies and strategies forprevention, response, and recovery, Internat J Emergency Mental Health 9:4 2008.Hammer R: Caring in forensic nursing: expanding the holistic model, J Psychosoc Nurs 38:18, 2000.Heim C, Nater UM, Maloney E, Boneva R, Jones, JF, Reeves WC: Childhood trauma and risk for chronic fatigue syndrome, Arch GenPsychiatry 66:1, 2009.Hill J, Nathan R: Childhood antecedents of serious violence in adult male offenders, Aggressive Behavior 34:329, 2008.Hinds J: Once upon a time: therapeutic stories as a psychiatric nursing intervention, J Psychosoc Nurs Ment Health Serv 35:46, 1997.Howe EG: Treating torture victims and enhancing human rights, Psychiatry 66:65, 2003.Hughes FA, Thom K, Dixon R: Nature and prevalence of stalking among New Zealand mental health clinicians, J Psychosoc Nursing 45:4, 2007.Institute for Safe Medication Practices: For most nurses, intimidation is commonplace, RN 67:17, 2004.Jonzon E, Lindblad F: Adult female victims of sexual abuse, J Interpers Violence 20:651, 2005.Jordan CE: Intimate partner violence and the justice system, J Interpers Violence 19:1412, 2004.Katchen MH: Ritual abuse vs. religious abuse: the development of an artificial distinction, MKzine 3:9, 2005.Kreidler MC, Zupancic MK, Bell C, Longo MB: Trauma and dissociation: treatment perspectives, Perspect Psychiatr Care 36:77, 2000.Lacy TJ, Benedek DM: Terrorism and weapons of mass destruction: managing the behavioral reaction in primary care, South Med J 96:394,2003.Lanza ML, Zeiss RA, Rierdan J: Multiple perspectives on assault: The 360-degree interview, J Amer Psych Nurses Assoc 14:6, 2009.Leiper J: Nurse against nurse: how to stop horizontal violence, Nursing 2005 35:44, 2005.Leone JM, Johmson MP, Cohan CL: Victim help seeking differences between intimate terrorism and situational couple violence, FamilyRelations 56:427, 2007.Lewis-O’Conner A: “Dying to tell?” Do mandatory reporting laws benefit victims of domestic violence? Am J Nurs 104:75, 2004.Lie D, Barclay L: Consequence of childhood sexual abuse similar for both sexes, Medscape CME Retrieved from www.medscape.com. AccessedJuly 11, 2005a.Lie D, Barclay L: Patients might prefer that physicians ask about family conflict, Medscape CME Retrieved from www.medscape.com. AccessedJune 3, 2005b.Liston C: Some brain effects of stress may be reversible, Harvard Mental Health Letter, June, 2009.Logan TK, Walker R: Separation as a risk factor for victims of intimate partner violence: beyond lethality and injury, J Interpers Violence19:1478, 2004.Martin L, Rosen LN, Durand DB, et al: Psychological and physical health effects of sexual assaults and nonsexual traumas among male andfemale United States Army soldiers, Behav Med 26:23, 2000.Maso SW, Anderson L: Sexual assault in men: A population-based study of Virginia, Violence and Victims 24:1 2009.Spinhoven P, Slee N,Garnefski N, Arensman E: Childhood sexual abuse differentially predicts outcome of cognitive-behavioral therapy for deliberate self harm, JNervous and Mental Disease, 197:6, 2009.Mawson AR: Intentional injury and the behavioral syndrome, Aggression Viol Behav 10:375, 2005.McClellan AC, Killeen MR: Attachment theory and violence toward women by male intimate partners, J Nurs Scholarship Fourth Quarter:353,2000.McCollough-Zander K, Sarson S: “The fear is still in me”: caring for survivors of torture, Am J Nurs 104:54, 2004.McFarlane J, Malecha A, Gist J, et al: Increasing the safety-promoting behaviors of abused women, Am J Nurs 104:40, 2004.McGonigle HL: The law and mind control, S.M.A.R.T. News, August 15, 1999.Merrell J: Social support for victims of domestic violence, J Psychosoc Nurs 39:30, 2001.Miller MC: The biology of child maltreatment, Harv Ment Health Lett 21:1, 2005.Miller MC: Countering domestic violence, Harv Ment Health Lett 20:1, 2004.Monarch K: Protect yourself from sexual harassment, Am J Nurs 100:75, 2000.Morrison EF, Love CC: An evaluation of four programs for the management of aggression in psychiatric settings, Arch Psychiatr Nurs 17:146,2003.Murphy CM, Winters J, O’Farrell TJ, et al: Alcohol consumption and intimate partner violence by alcoholic men: comparing violent andnonviolent conflicts, Psychol Addictive Behav 19:35, 2005.Muscari ME: What should I do when a client is being stalked? Medscape Nurses 7:1, 2005. Retrieved from www.medscape.com. Accessed July11, 2005.Mynatt S: Repeated suicide attempts, J Psychosoc Nurs 38:24, 2000.Naifeh JA, North TC, Davis JL, Reyes G, Logan CA, Elhai JD: Clinical profile differences between PTSD-diagnosed military veterans and crimevictims, J Trauma & Dissociation 9:3, 2008.New York Academy of Medicine: Worksite crisis intervention helped New Yorkers curb level of mental distress for up to two years after theWorld Trade Center disaster, LifeNet 16:1, Fall 2004/Winter 2005.Osterman JE, Barbiaz J, Johnson P: Emergency interventions for rape victims, Psychiatr Serv 52:733, 2001.Paul J, Blum D: Workplace disaster preparedness and response: the employee assistance program continuum of services, Int J Emerg MentHealth 7:169, 2005.Pasquali EA: Humor: an antidote for terrorism, J Holistic Nurs 21:398, 2003.Peternelj-Taylor C: Forensic psychiatric nursing: a work in progress, J Psychosoc Nurs 39:8, 2001.Phillips G: Guide to health helplines and crisis hotlines, Bottom Line Women's Health, September, 2008.Piercy D, Greenwood M: DOVE program takes flight, Nurs Spectrum (Metro Edition) January:18, 2002.Poirier N: Psychosocial characteristics discriminating between battered women and other women psychiatric inpatients, J Am Psychiatr NursAssoc 6:144, 2000.Ragavan C, Guttman M: Terror on the streets, U.S. News and World Report, December 13, 2004, p. 21.RAINN: Hotline for sexual assault victims goes digital, J Psychosoc Nurs 46:6, 2008.Ramsey-Klawsnik H, Teaster PB. MendiondoMS, Abner EL, Cecil KA, Tooms MR: Sexual abuse of vulnerable adults in care facilities: Clinicalfindings and a research initiative, J Am Psychiatr Nurses Assoc 12:6, 2007.Ray SL: Male survivors’ perspectives of incest/sexual abuse, Perspect Psychiatr Care 37:49, 2001.Rick S, Douglas DH: Neurobiological of childhood abuse, J Psychosoc Nurs 45:4, 2007.Roberts SJ: Primary health care of survivors of childhood sexual abuse: how can psychiatric nurses be helpful? J Am Psychiatr Nurses Assoc6:191, 2000.Roberts NP, Kitchiner NJ, Kenardy J, Bisson JI: Systematic review and Meta-analysis of multiple-session early interventions following traumaticevents, Am J Psychiatry 166:3 2009.Rothschild B: The body remembers: the psychophysiology of trauma and trauma treatment, New York, 2000, WW Norton.Rowell PA: The victor(y) over interpersonal trauma, J Am Psychiatric Nurses Assoc 11:103, 2005.Sarson J, MacDonald L: Behavioural Harms: Enforced and survival tactics in ritual abuse-torture. Paper presentation at the 31st SALISConference, May 8, 2009.Sarson J, MacDonald L: Human trafficking and ritual abuse-torture From Persons against Ritual Abuse-Torture. Available athttp://www.ritualabusetorture.org. Accessed August 5, 2004.Schwecke LH: Childhood sexual abuse, PTSD, and borderline personality disorder, J Psychosoc Nurs 47:7, 2009.Shea DJ: Effects of sexual abuse by catholic priests on adults victimized as children, Sexual Addiction & Compulsivity 15:250, 2008.Simon TR, Kresnow M, Bossarte: Self reports of violent victimization of U.S. adults, Violence and Victims 23:6, 2008.Spangler D, Brandl: Abuse in later life: Power and control dynamics and a victim centered response, J Am Psychiatr Nurs Assoc 12:6, 2007.Starr DL: Clients who self-mutilate, J Psychosoc Nursing 42:33, 2004.Stith SM, Smith DB, Penn CE, et al: Intimate partner physical abuse perpetration and victimization risk factors: a meta-analytic review,Aggression Violent Behav 10:65, 2004.Strasser SM, Fulmer T: The clinical presentation of elder neglect: What we know and what we can do, J Am Psychiatr Nurs Assoc 12:6, 2007.Stringer H: Raging bullies, Nurse Week February 12:10, 2001.Surprising New Research: J Nervous and Mental Disease 197:6, 2009.The crime of human trafficking: A law enforcement guide to Identification and Investigation: Department of Justice, Office on Violence AgainstWomen, date unknown.Tilley DS, Brackley M: Violent lives of women: critical points for intervention—phase I, focus groups, Perspect Psychiatr Care 40:157, 2004.Tolces R: Electronic harassment, MKzine 3:5, 2005.Torem MS: The role of medication in treatment of dissociative disorders, Many Voices 12:6, 2000.Trossman S: Illinois RNs win workplace safety measures, Am Nurse January/February:1, 2001.Trossman S: Issues up close: The costly business of human trafficking, American Nurse Today#:12, 2008.Trossman S: Issues up close: ANA brings nurses, experts together to shape practice policy during disasters, Amer Nurse Today, March, 2007.Turkus JA: The treatment challenge, Many Voices 12:6, 2000.Tynhurst JS: Individual reactions to community disaster, Am J Psychiatry 107:764, 1951.Valente SM: Controversies and challenges of ritual abuse, J Psychosoc Nurs 38:8, 2000.Valente SM: Sexual abuse of boys, J Child Adol Psychiatr Nurs 18:10, 2005.van der Kolk B, McFarlane AC, Weissaeth L: Traumatic stress: the effects of overwhelming experience on mind, body, and society, New York,1996, Guilford Press.Walker L: The battered woman, New York, 1979, Harper & Row.Wessells M: Supporting the mental health and psychosocial well-being of former child soldiers Am Acad Child Adol Psychiatry 48:6, 2009.Whitaker DJ: Domestic violence: Not always one sided, Harvard Mental Health Letter, 24:3, 2007.Williams KR: Arrest and intimate partner violence: toward a more complete application of deterrence theory, Aggression Violent Behav 10:660,2005.Williams KA, Bydalek K: Self-mutilation: The cutting truth, Amer Nurse Today 4:8, 2009.Willis DG: Male-on-male rape of an adult man: A case review and implications for interventions, J Am Psychiatr Nurs Assoc 14:6, 2009.Woods SJ, Wineman NM: Trauma, posttraumatic stress disorder symptom clusters, and physical health symptoms in post-abused women, ArchPsychiatr Nurs 18:26, 2004.Worthington K, Franklin P: Workplace violence, Am J Nurs 100:73, 2000.Young BJ, Furman W: Interpersonal factors in the risk for sexual victimization and its recurrence during adolescence, J Youth Adol 37:297,2008.FIGURE 41-1 The desire for power and control results in both psychological and physical abuse. (From Domestic Abuse Intervention Project:Power and control, Duluth, MN, 1987, Domestic Abuse Intervention Project.)

About Me

I retired Jan. 2009 from after 33 years on the criminal justice faculty at Indiana University, Bloomington. I continue not to charge for any form of public service, including speaking and consulting, and now have plenty of free time to do so on request. I do not do social networking. I regularly monitor just one email account: pepinsky@indiana.edu; my home phone number is 1-614-885-6341; my skype name is halpep. My papers and such are archived at http://webapp1.dlib.indiana.edu/findingaids/view?brand=general&docId=InU-Ar-VAA9639.xml&doc.view=entire_text.
I am known as a co-founder of "peacemaking criminology." Page proofs of my latest, 2006 U of Ottawa Press book, Peacemaking: Reflections of a Radical Criminologist, are freely available at http://critcrim.org/sites/default/files/Pepinsky_proofs_0.pdf , the end of which lists my publications, nine books and over 80 articles and chapters in all, on a wide range of subjects from the international to the interpersonal level. My preceding book, A Criminologist's Quest for Peace, is also freely available at http://critcrim.org/pepinsky, and a pdf of Myths That Cause Crime is on the critcrim.org home page.